Every finding on record at Pecan Tree Rehab and Healthcare Center

Based on interview and record review, the facility failed to ensure each resident was free from abuse for one (Resident #4) out of 5 residents reviewed for abuse and neglect. The facility failed to ensure the LVN did not cause mental anguish to Resident #4 when she accused her of pulling her I.V. out for attention. This failure could place residents at risk for abuse, neglect and a decline in psychosocial well-being.Record review of Resident #4's face sheet revealed she was an [AGE] year-old female who was admitted [DATE]. Her diagnoses included: Displaced Fracture of base of neck of Right Femur (serious hip injury where bone is broken and shifted out of place), Unspecified Fracture of Right Patella (broken kneecap), Essential Hypertension (high blood pressure), Unspecified Atrial Fibrillation (presence of rapid, irregular heart rhythm), and Dizziness (lightheaded). Record review of Resident #4's Admissions MDS dated [DATE] revealed a BIMS of 9 which meant moderate cognitive impairment. Resident #4's MDS revealed she had the ability to understand others with clear comprehension. Record review of Resident #4's Care Plan dated 5/11/26 and revised on 5/12/26 revealed she had an ADL self-care deficit, and a history of trauma that may have a negative impact. The trauma was related to a verbal conversation with staff member. Interventions were listed as:arrange for licensed mental health provider as ordered by physicianif resident is escalated, do not touch the residentto monitor for escalating anxiety, depression or suicidal thought and report immediately to the nurse. Record review of Resident #4's Progress Notes on 5/8/26 at 11:36 p.m. written by the LVN revealed Resident #4 had pulled her iv out of her arm with about 25% of fluid left in iv bag resident reports she didn't realize she had pulled it out. Record review of Tulip revealed a report was called in on 5/11/26 regarding the alleged abuse of Resident #4 by the LVN. Interview on 5/12/26 at 9:48 a.m. the ADON stated Resident #4 pushed her call light to let nurse know her I.V. came out. Resident #4's FM was on the phone when the LVN came in saying she pulled out her I.V. for attention but the resident stated she had not. The ADON stated the FM thought the LVN saw she was on the phone and the LVN changed her attitude. Interview on 5/12/26 at 9:50 a.m. the Admin. stated Resident #4 called the LVN the mean nurse. The Admin. stated the LVN reportedly told Resident #4 she took out her I.V. on purpose. The Admin. found out about potential abuse yesterday, 5/11/26, when the FM called the SW. The SW had him and the ADON come into her office. He stated that was why he called in the report right after he heard about it. The Admin. stated Resident #4 was a little emotional and cried a little bit. He suspended the LVN immediately pending investigation to make sure no psychosocial issues were going on but otherwise, Resident #4 was fine. Interview on 5/12/26 at 10:54 a.m. Resident #4 stated the LVN accused her of taking her I.V. out on purpose. She stated it made her feel awful as (she) did not do stuff like that. Resident #4 stated her FM was on the phone and heard what happened. She stated the FM called the facility and let them know. Resident #4 stated she felt like all that should happen was the LVN was moved off her hall and that was done. Interview on 5/12/26 at 1:13 p.m. Resident #4's FM stated she was on the phone when the incident happened with the LVN. The FM stated Resident #4 accidentally called her without knowing. The FM stated the LVN was in the room, and she heard her chewing her (Resident #4) out and accusing her of pulling her I.V. out for attention. The FM stated the LVN was treating her like crap. She stated Resident #4 was crying and said she did not do it on purpose and that she did not do it for attention, I promise. The FM stated she felt the LVN was very ugly to Resident #4. She stated the LVN must have noticed she was on the phone because she changed her behavior and was saying Oh baby it is ok; everything is going to be ok. The FM stated Resident #4, and she referred to the LVN as the mean nurse. The FM stated Resident #4 was afraid to death of her and did not want to take medications from her anymore. The FM stated she called the SW on 5/11/26 and let her know what had taken place. She stated Resident #4 told her she did not want anyone to get in trouble. The FM told her she did not need to be abused either. The FM stated she felt Resident #4 would be fine after the incident and the facility stated they would not have the LVN working on her hall anymore. Interview on 5/12/26 at 2:19 p.m. the SW stated she talked to Resident #4's FM yesterday (5/11/26). The SW stated the FM had to call her back, so she had the ADMIN. and ADON in the room and had the FM on speaker phone. The SW stated the FM stated the LVN had gone into Resident #4's room and berated her for pulling her I.V. out. The SW stated the FM stated the LVN's behavior changed when she must have seen the FM was on the phone. The SW stated she interviewed Resident #4 for trauma but there was nothing lingering. She had made multiple checks on Resident #4 and she was fine. The SW had not heard any complaints regarding the LVN before. She stated people complained about staff, but not to this level. The SW stated the FM said Resident #4 was crying when the LVN was talking to her. Interview on 5/12/26 at 2:40 p.m. the LVN stated Friday evening, 5/8/26, Resident #4's call light was on, and she went in and saw her I.V. had dislodged. She stated she told Resident #4 you pulled your I.V. out. The LVN stated Resident #4 said it must have happened when she was choking. The LVN stated she told her she was ok. The LVN denied telling Resident #4 she did it on purpose or for attention but did tell her she pulled it out. She denied Resident #4 was crying and stated there were no tears. The LVN stated she did not know the FM was on the phone during the conversation. She stated the FM would have heard the entire conversation. The LVN stated she had never had any problems/complaints before. She stated she was written up for telling an aide to take care of the residents. The LVN stated if she or any staff had talked to any resident accusing them of pulling their I.V. out for attention, the resident could think they did something wrong when they did not. The LVN stated she thought the FM took the conversation out of context and stated 25% of the conversation was coddling Resident #4, not accusing her. Interview on 5/12/26 at 2:58 p.m. the DON stated on 5/11/26, she did a head-to-to-toe assessment on Resident #4, talked to her, and let her know to talk to her if she was feeling a certain way. She stated the LVN would not be taking care of Resident #4 anymore and she assured the family members. The DON stated she had never had any issues with the LVN personally before but knew she had been written up in the past. She stated the former management team possibly had an issue with the LVN. The DON stated she was surprised the allegation came in regarding the LVN as she had been so attentive towards Resident #4. The DON stated a resident being accused of something like pulling their I.V. out or being talked down to, could cause psychosocial harm to the resident. Interview on 5/12/26 at 3:10 p.m. the Admin. stated the LVN had been written up before he started working at the facility with the new management team on 3/16/26. He stated he could not act on anything that was before he started at the facility. He stated when he found out this potentially happened, he suspended her immediately and planned on letting the LVN go. The Admin. stated what the LVN did was abuse. Record review of the facility's Abuse/Neglect policy dated 3/29/18 revealed The resident has the right to be free from abuse.Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff.Under Definitions:Abuse is the willful infliction of.intimidation, or punishment with resulting.mental anguish.It includes verbal abuse.and mental abuse. 6. Mental Abuse: includes, but is not limited to, humiliation, harassment. Under Prevention: The facility will provide the residents, families, and staff an environment free from abuse and neglect.

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 4 of 8 residents (Resident #42, Resident #53, Resident #76, and Resident#5) observed for infection control. 1-The facility failed to ensure LVN B sanitized the blood pressure cuff (a reusable equipment) between residents (Resident#53, and Resident#76) use on 02/17/2026. 2-The facility failed to ensure CNA A performed hand hygiene while providing incontinent care to Resident #42 on 02/17/2026. 3-The facility failed to ensure CNA A and CNA B performed hands hygiene while performing Resident#5 mechanical transfer from bed to a shower chair on 02/16/26 These failures could place residents at risk for development of infection. 1-Record review of Resident #76's Doctor's orders summary dated 09/03/2024 and still active on 02/17/2026 revealed Metoprolol Tartrate tablet give 12.5 mg by mouth two times a day related to essential (primary) hypertension hold for SBP less than 110, DBP less than 60, pulse less than 60. Recorder review of Resident #53's Doctor's orders summary dated 01/02/2026 and still active on 02/17/2026 revealed Losartan potassium oral tablet 25 mg give 1 tablet by mouth one time a day related to essential (primary) hypertension hold for SBP less than 100. Observation on 02/17/26 at 07:56 AM, reflected LVN B checked Resident #76's blood pressure, and put the blood pressure cuff on top of the medications cart, she prepared the morning medications and gave it to Resident #76 using proper hand hygiene. LVN B used the same blood pressure cuff without sanitizing it, checked Resident #53's blood pressure and put it on the top of the medications cart. In an interview on 02/17/26 at 08:10 AM, LVN B stated she sanitized the blood pressure cuff sometimes but not every time she used it between residents. When asked about the facility policy on sanitizing the reusable equipment between residents, she replied she was supposed to sanitize the blood pressure cuff each time she used it and before using it on another resident. LVN B stated the risk of not following proper sanitization of the reusable equipment was cross contamination and development of infection for the residents. 2-Record review of Resident #42's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old male admitted to the facility on [DATE], and readmitted [DATE] with the diagnoses of hypertension (elevated blood pressure), type 2 diabetes (elevated blood sugar), and cerebrovascular accident (occurs when blood flow to the brain is interrupted, leading to brain damage). Resident #42 had a BIMS score of 07, which indicated severe cognition impairment. Further review revealed urinary continence/ bowel continence were coded as frequently incontinent. Record review of Resident #42's care plan dated 12/17/25 reflected, focus: the Resident have an ADL Self Care Performance Deficit r/t stroke, impaired balance Goal: the Resident will maintain current level of function /minimize decline through the review date. Intervention/Tasks: toilet use: the Resident needs assistance from staff.[sic] Observation on 02/17/26 at 08:52 AM, reflected CNA A entered Resident #42's room washed hands, put on clean gloves and explained to the resident that she was to provide incontinent care. CNA A positioned the resident and unfastened his brief, then proceeded to clean the resident. Resident#42's brief was soaked with urine. CNA A cleaned Resident #42's front area, removed gloves, and put on clean gloves without performing any form (hands sanitizing of hands washing) of hand hygiene. CNA A helped Resident #42 turn to his left side. CNA A removed the dirty brief, put it in the trash can, changed gloves without performing any form of hand hygiene. When CNA A completed cleaning Resident #42's buttocks area, she applied the clean brief on Resident #42 without changing gloves. CNA A removed gloves, covered the resident, and moved the bedside table closer to the resident. After care, CNA A completed hand hygiene and exited the room. In an interview on 02/17/26 at 09:05 AM, CNA A stated she was to complete hand hygiene before and after care and after taking off Resident #42's dirty brief. CNA A stated she was supposed to change her gloves with hand hygiene after she cleaned the resident before applying the clean brief. CNA A stated she was supposed to sanitize her hands each time she removed the dirty gloves before putting on the clean gloves, but she forgot to bring hand sanitizer with her. CNA A stated not following proper hand hygiene and infection control policy could lead to cross contamination and development of infection for residents. In an interview on 09/25/25 at 2:40 PM, the DON stated infection control was important during care. The DON stated during care the staff was to use hand sanitizer or wash hands if they were physically soiled. The DON stated the staff was expected to complete hand hygiene before care and after care, he also stated during incontinent care the staff was supposed to change gloves and use hand sanitizer when taking off the dirty brief before applying the clean brief. The DON stated proper hand hygiene and following proper infection control was to be followed to prevent the development infections for residents and staff. 3-During interview and observation on 02.16.2026 at 1:00 PM Resident #5 was transferred by Hoyer lift from his bed to a shower chair by CNA A who has worked at this facility for five years; and CNA B who has worked at this facility for five months. Both CNAs were observed to put on PPE. The gowns were put on correctly. The first set of gloves were put on without hand hygiene. Both CNAs were observed to change their gloves four times each without performing hand hygiene between glove change while transferring Resident #5 by Hoyer lift from his bed to the shower chair Resident #5 was observed to be on enhanced barrier precautions.MDS record review on 02.16.26 at 1:13 PM Resident #5 - BIMS score 15 reflected the resident could be interviewed. Section GG states resident requires moderate assistance for ADLs. No skin issues noted in the current MDS. Resident is on enhanced barrier precautions for a supra-pubic urinary catheter.Record review on 02.16.2026 at 1:30 PM of comprehensive care plan dated 01.18.2026 revealed Resident #5 required extensive assistance with ADLs due to immobility and joint contracture. The resident requires transfers by Hoyer lift with assistance of two CNAs. The resident was at risk of skin integrity due to medically complex conditionsOn 02.16.26 at 2:45 PM a review of Infection Control Policy dated 3.2024 revealed: Infection Control Policy/Procedure The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility will establish an Infection Control Program under which it - Investigates, controls, and prevents infections in the facility. Decides what procedures, such as isolation, should be applied to an individual resident; and Maintains a record of incidents and corrective actions related to infections. Facility Assessment / Infection Prevention and Control Assessment Tool for Long-term Care Facilities At least annually and on an as-needed basis the facility will conduct a facility-wide assessment to determine the resources needed to maintain an efficient and up-to-date infection control program. Review of the facility Infection control Plan: Overview updated 03/2024 revealed .6. Resident care equipment and articles Non-invasive resident care equipment is cleaned daily or as needed between use by the nursing Assistant Equipment that is visibly soiled with blood or body fluids will be cleaned immediately with an approved disinfectant by the nursing assistant. A documentation system will be maintained of the cleaning. Review of the facility policy undated and titled Hand Hygiene reflected, Hand hygiene continues to be the primary means of preventing the transmission of infection. When to perform hand hygiene .Gloving: Gloves are worn for three important reasons:1 To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin. The wearing of gloves in specified circumstances will reduce the risk of exposures to blood-borne pathogens and is mandatory for all employees. 2 To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to residents during invasive or other resident-care procedures that involvetouching a resident's mucous membranes and nonintact skin. 3 To reduce the likelihood that hands of personnel contaminated with microorganisms from a resident or a fomite can transmit these microorganisms to another resident; in this situation, gloves must be changed between resident contacts, and hands washedafter gloves are removed. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves between resident contacts is an infection control hazard.

Based on observations, interviews and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items were properly stored in the facility kitchen on 02/18/26. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness and food contamination.Findings included: Observation on 02/18/26 at 9:10 AM of the refrigerator in the kitchen area revealed a tray containing six uncovered pies on the middle shelf placed on top of a container full of 3 packages of raw frozen chicken. An interview with the Dietary Manager on 02/18/2026 9:23 AM revealed raw foods should be placed on the bottom rack in case it leaks to avoid contamination. The Dietary Manager stated the pies should have been covered to avoid anything getting on them and to avoid contamination. The Dietary Manager stated kitchen staff completed food handlers training within the first 30 days of hire. The Dietary Manager stated kitchen staff was last in-serviced on food storage procedures 6 months ago. An interview with the Dietary Aide on 02/18/26 at 1:14 PM revealed she placed the pies on top of the container of chicken. She stated the pies were uncovered and she didn't think about it. She stated the pies should have been covered to prevent cross contamination and to prevent anything from falling on them. She stated residents could get sick from cross contamination. An interview with the Dietary [NAME] on 02/18/26 at 1:23 PM revealed she placed three bags of chicken on the middle shelf of the refrigerator the night prior because there was not room on the bottom shelf. She stated it was important to place raw meat on the bottom shelf in case it leaked, it would cause cross contamination. Review of the facility's policy titled Dietary Services Policy and Procedure manual 2012 reflected, .Frozen items that should be thawed before preparation should be stored under refrigeration until thawed. The U.S. Food and Drug Administration reflected the following, . Keep foods covered: Store refrigerated foods in covered containers or sealed storage bags, and check leftovers daily for spoilage. The Centers for Disease Control and Prevention Food Safety, dated April 2024, reflected the following, .In the refrigerator: Keep your chicken stored on the bottom shelf of the refrigerator in a sealed container or wrapped securely so the juice doesn't leak onto other foods.

Based on observation, interview and record review, the facility failed to ensure that residents receive care consistent with professional standards of practice based on the comprehensive assessment for two (Resident #5 and Resident #75) of nine residents reviewed for pressure ulcers.The facility failed to ensure Resident #5, and Resident #75 were provided with a weekly skin assessment that reviewed total body skin surfaces with accurate clinical documentation of skin integrity. This oversight resulted in the development of skin injuries that were undocumented and untreated. The facility nursing staff failed to identify, document, or notify the primary physician for appropriate treatment and services.This failure could place all residents at risk of developing skin injuries and not receive appropriate treatment and services that affect quality of care and quality of life. Findings include: Record review of face sheet dated 02.16.26 for Resident #5 revealed a [AGE] year-old-male admitted to the facility on 12.16.2025. Diagnoses: acute cystitis (urinary bladder infection) with hematuria (blood in urine), type two diabetes mellitus, severe protein/calorie malnutrition, major depressive disorder, (severe depression), and encephalopathy (brain disorder causing confusion and memory loss). Record review of MDS dated 01.20.2026 revealed a BIMS score of 15 indicated intact cognition. Section GG - functional abilities revealed the resident required extensive assistance of two staff with activities of daily living. Section I - active diagnosis revealed medically complex conditions. Section M - skin conditions revealed no pressure injuries, arterial or venous ulcers. Record review of comprehensive care plan dated 01.18.2026 revealed Resident #5 required extensive assistance with ADLs due to immobility and joint contracture. The resident required transfers by a mechanical lift with assistance of two CNAs. The resident was at risk of skin integrity due to medically complex conditions. During interview and observation on 02.16.2026 at 1:00 PM Resident #5 was transferred by Hoyer lift from his bed to a shower chair by CNA A and CNA B. During the transfer the residents' feet were observed to be bare. A 1cm by 1cm by 0.5 cm deep round black area was observed on the ball of the resident's left foot without a bandage present. CNA A and CNA B stated they were unaware of the skin issue identified. Both CNAs were asked what the expectation was for identifying new skin issues during the process of showering residents. CNA A, who had worked at the facility for five years, stated new skin issues identified during showering residents were reported to the charge nurse immediately. CNA B stated she had worked at this facility for five months and was still learning policy and procedure. Record review of skin assessments for Resident #5 dated 01.08.2026, 01.20.2026, 01.27.2026, 02.13.2026 revealed no documentation related to the identified skin injury to the ball of the left foot. Interview with CNA A on 02.17.26 at 9:10 AM revealed she did not notify the charge nurse of the skin issue identified to the ball of the left foot for Resident #5 on 02.16.26. She stated she meant to notify, but she got busy and forgot. Interview with CNA B on 02.17.26 at 9:13 AM revealed she did not notify the charge nurse of the skin issue identified to the ball of the left foot for Resident #5 as she forgot about the conversation. Interview on 02.17.2026 at 9:15 AM with LVN E revealed he has worked at this facility for eight years. He was the charge nurse for Resident #5 on the 6:00 AM to 2:00 PM shift, Monday through Friday. He stated he was unaware of a skin injury to the ball of the left foot for Resident #5. LVN E stated the CNAs were the first-line staff to do skin assessments while performing personal care or showers for residents. He stated the CNA reports skin changes to the charge nurse; the charge nurse makes an assessment then fills out a skin report worksheet and gives it to the treatment nurse. The treatment nurse calls the physician and gets a treatment order and starts treatment and documentation. Interview and observation on 02.17.2026 at 9:30 AM with the facility treatment nurse revealed she had worked at this facility since June 2024. She stated she was unaware of a new skin injury for Resident #5. She was observed to go to Resident #5 and perform a skin assessment and confirmed she was unaware of the change in skin condition. The resident was asked if he was aware of the change in his skin on his left foot. He stated he was unaware and became visibly and verbally upset. Interview on 02.17.2026 at 9:45 AM with LVN E revealed weekly skin assessments are divided between 6:00 AM to 2:00 PM nurses and the 2:00 PM to 10:00 PM nurses. The same nurses perform the same resident skin assessments for continuity of care. The expectation was that CNAs look at all skin surfaces while showering residents. If a change in skin is observed the CNA reports to the charge nurse who performs a skin assessment and documentation is sent to the facility treatment nurse. Interview and observation on 02.17.2026 at 10:00 AM with treatment nurse revealed she performed head-to-toe skin assessments quarterly on residents with no identified skin issues. She assessed residents with known wounds weekly accompanied by the wound care physician. Record review of Resident #75's face sheet dated 02.17.2026 revealed a [AGE] year-old-male admitted to the facility on 05.23.2024 with the following diagnoses: COPD (lung disease causing difficult breathing), Alzheimer's disease, dysphagia (difficult swallowing), major depressive disorder (depression), and type two diabetes mellitus. Record review for Resident #75 of MDS dated 12.13.2025 revealed the resident had a BIMS score of 3 that indicated severe cognitive impairment. Section GG - functional abilities revealed the resident requires extensive assistance from two staff for activities of daily living. Section M - skin condition revealed no documented pressure injuries, arterial or venous ulcers. Record review of comprehensive care plan for Resident #75 revealed resident had a deficit in self-care performance and activity intolerance due to limited range of motion of upper and lower extremities. Interview and observation on 02.17.2026 at 11:30 AM with LVN C and CNA D revealed during a skin assessment for Resident #75 they were unaware of a change in the skin on the second and third toes on the resident's right foot. 1 cm by 1cm by 0 cm areas on both toes were observed to be black with redness surrounding the black areas. Record review for Resident #75'sr weekly skin assessments dated 01.09.2026, 01.26.2026, 02.09.2026, and 02.16.2026 all revealed no documentation for a change in skin condition to the second and third toes on the right foot. Interview on 02.17.2026 at 1:35 PM with Director of Nurses revealed several changes that had occurred with the new administration. She stated there was no policy for the shower or skin worksheets used previously, and they were no longer being used as of this week. Her expectations were for CNAs to verbally tell charge nurses about changes in skin condition for residents instead of using worksheets. The expectation now was after the CNA tells the charge nurse of a change in skin condition; the charge nurse was responsible for doing a skin assessment. If a wound was identified, the wound care vendor was notified. The wound care physician assumes treatment care. The wound care physician visits the facility weekly and reviews wound care with the facility treatment nurse. The charge nurses document weekly skin assessments in the electronic clinical record. The DON stated the CNAs are the front-line staff performing skin assessments while providing routine skin care during personal care or showers. The charge nurses are responsible for notifying the physician and family of a change in resident condition. She stated if skin issues are not recognized in time to prevent further injury, a self-report to the State will be made. Telephone interview on 02.17.2026 at 2:46 PM with the facility medical director revealed his expectations for the facility nursing staff related to reporting skin issues was for him to be notified as soon as possible. He stated many times he was not notified by the facility nursing staff because they notified the wound care vendor first. He stated his consultation was needed before calling the wound care vendor. He stated he was the primary care provider for Residents #5 and #75 and unaware of any change in skin condition for these residents. Review of Skin Monitoring: Comprehensive CNA Shower Review worksheets for Resident #5 for dates: 01.30.2026, 02.02.2026, 02.04.2026, 02.06.2026, 02.09.2026, 02.11.2026, 02.13.2026, and 02.16.2026 revealed no documentation of skin change on the ball of the resident's left foot. The worksheets were signed by the CNA providing care and the Charge Nurse. Review of Skin Monitoring: Comprehensive CNA Shower Review worksheets for Resident #75 on for dates: 01.30.2026, 02.02.2026, 02.04.2026, 02.06.2026, 02.09.2026, and 02.16.2026 revealed no documentation of skin change on the second and third toes of the resident's right foot. The worksheets were signed by the CNA providing care and the Charge Nurse. Record review of podiatry notes dated 01.15.2026 for resident #75 revealed no documentation or recommendation of treatment to the second and third toes of the resident's right foot. Telephone interview with Wound Care Physician on 02.18.26 at 10:30 a.m. revealed she had been notified by the facility on 02.17.2026 at 5:30 PM of two residents that had skin issues. The physician stated that telehealth visits were conducted for Residents #5 and #75. She stated residents with diabetes have circulatory problems, and she will not know what stage of pressure ulcer was below the dead black skin until it was surgically removed. With removal of the dead skin tissue the injury can be determined at stage one, two, three, or four. She stated the skin injuries for Resident #5 and Resident #75 are considered unavoidable due to the medical conditions of the residents. Interview with Director of Social Services on 02.18.26 at 10:50 AM. she stated the facility used a vendor for podiatry care for all diabetic residents. She stated the CNAs and Nurses are the front-line staff that assess skin and reports problems. When a foot issue is identified for a diabetic resident, Social Services is notified, and she contacts the vendor and makes the appointment for the resident to be seen. The Podiatrist comes to the facility and provides care. After care, the podiatrist sends an email with care notes, treatments provided, and any orders or treatments required. This document is scanned into Point Click Care for the resident record. The DON and administrator are cc'd on this email. Interview on 02.18.2026 at 11:30 AM with LVN E revealed when the podiatrist sees a resident, the charge nurse should check the documentation and make a skin treatment communication sheet that is passed to the treatment nurse. Interview on 02.18.2026 at 11:35 AM with treatment nurse revealed the skin treatment communication sheet is no longer in use at this facility. The expectation is that all communication between CNAs and nurses be verbal instead of using worksheets. Record review for resident #75 on 02.18.2026 at 12:00 PM revealed a skin assessment note dated 02.17.2026 at 11:51 AM had documentation strikes and new documentation entered that replaced original assessment. Record review for resident #5 on 02.18.2026 at 1:00 PM revealed a skin assessment note dated 02.17.2026 at 9:53 AM had documentation strikes and new documentation entered that replaced original assessment. Review of facility Foot Care policy, undated, revealed the goals for foot management: The resident will maintain intact skin integrity The resident will be free from infection The resident will remain free from injury to the feet Procedure: Become familiar with medical conditions that compromise circulation in the feet and assess for need of nail trimming Daily assessment of the feet should be done when care is given Record review of facility policy dated 08.12.2016 for Pressure Injury: Prevention, Assessment and Treatment revealed: Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse. The treatment nurse will: Notify the physician of pressure sore and obtain and follow any orders as directed by the physician Notify family and dietary department. Document Notification Director of Nursing or designee to in-service nurses and CNAs on prevention

Based on interviews and record reviews, the facility to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for quality of care. 1. The facility failed to ensure Resident #1's wound vac was providing the proper suction and failed to have her infected surgical wound assessed by the wound care physician or attending physician to determine the proper course of action, despite reports of complications. 2. The facility did not ensure proper management of Resident #1's clotted PICC line when it became clotted. Additionally, there was no dressing assessment documented for the PICC line. As a result of the PICC line not flushing, IV antibiotics were discontinued for the right hip surgical wound on 10/06/07 and oral antibiotics were started without addressing the central line's compromised condition. 3. Resident #1 had an unwitnessed fall on 10/07/25 with no noted injuries. After the fall, neurochecks were not completed per protocol from 10/07/25 to 10/08/25. On 10/08/25, Resident #1 fell again at the nurses' station and sustained a head injury. She was sent to the ER where it was determined she also had a left hip fracture.An IJ was identified on 10/17/25 at 11:48 AM. The IJ template was provided to the facility on [DATE] at 11:38 AM. While the IJ was removed on 10/18/25, the facility remained out of compliance at a scope of no actual harm and a severity level of pattern because the facility continued to monitor the implementation and effectiveness of their Plan of Removal and all nursing staff had not been trained on PICC line, neurochecks and wound vac therapy.These failures could result in could place residents at risk of not receiving care and treatment needed which could lead to avoidable decline and life-threatening complications.Findings included: Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others- ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no signs or symptoms of delirium and no negative mood issues. Resident #1 had no potential indicators of psychosis and no behavioral symptoms, no rejection of care issues and no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity. Resident #1 always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high-risk medications: anticoagulant (blood thinner), antibiotic and anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline upon admission. Record review of Resident #1's care plan initiated 09/25/25 and revised 10/08/25 reflected the following care areas: A. Focus: Resident has a surgical site to: R hip with negative pressure wound therapy to right hip at -125 continuously. Res frequently pulls wound vac off despite education. May use wet to moist dressing if dislodged (Date initiated: 09/25/25); Interventions/Tasks: 1) Surgeon follow up as needed. Assist resident/RP with scheduling/transportation as needed (Date Initiated: 09/25/25), Observe for s/s of infection-increased redness, increased pain, drainage. Report to physician if noted (Date Initiated: 09/25/25), Observe for s/s of pain during treatment and medicate PRN per physician's orders (Date Initiated: 09/25/2025), negative pressure therapy continuously (a treatment that uses continuous or intermittent negative pressure to promote wound healing. It involves applying a special dressing to the wound that creates a vacuum, removing fluid, debris, and bacteria from the wound bed )(added 10/03/25), Remove staples or sutures as ordered (added 10/08/25).B. Focus: The resident is on anticoagulant therapy. (Date Initiated: 10/08/25); Interventions/Tasks: Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (Date Initiated: 10/08/2025)C. Focus: The resident has Hip Fracture. (Date Initiated: 10/08/25); Intervention/Task: 1) Change surgical incision dressing as per order and PRN (Date Initiated: 10/08/25).D. Focus: The resident has Intravenous (IV) Access. (Date Initiated: 10/08/25); Interventions/Tasks: 1) Administer IV fluids as ordered (Date Initiated: 10/08/25), Administer IV medications as ordered (Date Initiated: 10/08/25), Check dressing at site daily. Monitor for signs and symptoms of infection, Drainage, Inflammation, Swelling, Redness, Warmth. if present notify the physician (Date Initiated: 10/08/25), Flush the ports/lines as ordered (Date Initiated: 10/08/25), If Tegaderm; change dressing every 7 days and prn-If gauze dressing change every 48 hours (Date Initiated: 10/08/2025), the resident has PICC line IV access (Date Initiated: 10/08/2025).E. Focus: The resident is risk for falls (Date Initiated: 10/08/25); Interventions/Tasks: 1) Anticipate and meet the resident's needs (Date Initiated: 10/08/25), 2) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Date Initiated: 10/08/25), 3) Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs (Date Initiated: 10/08/25), Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (Date Initiated: 10/08/25), Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (Date Initiated: 10/08/25), Keep furniture in locked position (Date Initiated: 10/08/25), Keep needed items, water, etc, in reach (Date Initiated: 10/08/25), Pt evaluate and treat as ordered or PRN (Date Initiated: 10/08/25), Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes (Date Initiated: 10/08/25), Staff x 2 to assist with transfers (Date Initiated: 10/08/25), The resident needs a safe environment (Date Initiated: 10/08/25), The resident needs activities that minimize the potential for falls while providing diversion and distraction (Date Initiated: 10/08/25) Record review of Resident #1's Fall Risk Assessment completed dated 09/24/25 reflected a score of 11, which indicated she was a high-risk. Record review of Resident #1's order summary reflected the prescribing physician was MD C and he ordered the following:- Clean wound to right hip with NS change granufoam and apply drape one time a day every Tue, Fri for wound (Start Date 09/24/25) -Clean wound to right hip with NS place granufoam and drape one time a day every Mon, Wed, Fri for wound (Ordered 10/03/2025 with start date 10/06/25)-Negative pressure wound therapy to right hip at -125 continuously every shift for wound (Start Date 10/03/25)-Negative pressure wound therapy to right hip continuous at -125 every shift for wound (Start date 09/24/25)-Bactrim DS Tablet 800-160 MG Give 1 tablet by mouth three times a day for bacterial infection for 10 Days (Start Date 10/06/25)-Bactrim DS Tablet 800-160 MG Give 2 tablet by mouth two times a day for bacterial infection for 10 Days (Start Date 10/07/25)-Cefazolin Sodium Injection Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection, R hip (Start Date 09/25/25) -Ertapenem Sodium Solution Reconstituted 1 GM Use 1 gram intravenously every 24 hours for infection, R hip for 1 Day (start date 09/24/25)-Lovenox Injection Solution Prefilled Syringe 40 MG/0.4ML (Enoxaparin Sodium) Inject 40 mg subcutaneously one time a day for R hip fracture related to for 28 Days (Start Date 09/25/25)-Saline Flush Intravenous Solution 0.9 % (Sodium Chloride Flush) Use 1 syringe intravenously every shift for IV antibiotics related to SEPSIS (start date 10/03/25)-Sodium Chloride Solution 0.9 % Use 10 ml intravenously every 8 hours for Flush 10 ml after each medication for 14 Days (Start Date 10/04/25)-Wet to moist dressing if dislodged every 4 hours as needed for wound (Start Date 10/03/25) Record review of Resident #1's September 2025 MAR reflected she was not administered her three antibiotic doses of Cefazolin on 09/25/25, her second day of admission at 1:00 AM (refused), 9:00 AM (refused) and 5:00 PM (away from facility). Record review of Resident #1's October 2025 medication administration record reflected that she was not administered her prescribed anticoagulant Lovenox or her IV antibiotic Cefazolin on 10/03/25. A nursing note by LVN D reflected, Resident refused, swatting at nurse. Further review reflected Lovenox was also not administered on 10/06/25, 10/07/25 and 10/08/25 with refusals again documented by LVN D on the MAR. Additionally, the oral antibiotic Bactrim, ordered by MD C on 10/06/25 was not administered until the morning of 10/07/25. Record review of Resident #1's admission Nursing Note by LVN A dated 09/24/25 reflected she admitted at 6:00 PM with her responsible party from the hospital. The nurse recorded her vitals and noted Resident #1 had a hip fracture, a PICC line on the right upper extremity, an anticoagulant and antibiotic ordered. Resident #1 was documented as non-mobile/bedfast and could not bear weight, required one person assistance for bed mobility and two-person assist for transfers. Record review of a facility admission Alert-Communication Alert for Approved Admissions for Resident #1 dated 09/24/25 at 3:36 PM and signed by LVN Q reflected the resident's ETA was 6:00 PM and her special requirements included ADL assist, IV meds and wounds. Equipment needs included PICC line and wound vac. A copy of the hospital discharge orders were included in the alert and reflected Resident #1 had Cefazolin (Ancef) 2 grams intravenously every eight hours and Ertapenem one gram intravenously every day. Record review of a Transfer Notification Progress Note by LVN A on 09/25/25 reflected, [Resident #1] was transferred to a hospital on [DATE] 8:30 PM related to vomiting black, meaty smelling emesis x 2. This is intended to serve as notice of an emergency transfer. A nursing note dated 10/02/25 by LVN A reflected Resident #1 re-admitted with a diagnosis of an upper GI bleed, was non-mobile and bedfast, was not oriented or alert and had memory impairment and she had a foley catheter in place. Record review of Resident #1's pertinent nursing progress note reflected:- (by WCRN B) 09/24/25 at 6:37 PM- Non-Ulcer Wound Assessment- Location of Area: Trochanter-Right, Type of Wound: Surgical, Length(cm):16, Width(cm):6, Depth(cm):4, Describe the wound appearance: Expose muscle, moderate exudate that is tan in color, No negative surrounding wound findings, No negative surrounding skin color findings, Odor: None, No pain associated with the wound. Interventions: Current wound treatment: granufoam; Frequency of wound treatment: 3 times a week, Other device: NA-Resident is non-compliant with treatment. Non-compliance consists of: confused and has no recall.-Record review of a Resident #1's nursing progress note by LVN A on 09/24/25 at 8:46 PM reflected the Ertapenem was not administered due to awaiting delivery from pharmacy.-Record review of a nursing progress note by LVN A on 09/24/25 at 9:45 PM reflected Resident #1 pulled her PICC line out on her own and it was found next to her bed with no active bleeding at insertion site and MD C was notified via text. There was no documentation to reflect the RP was notified. -Record review of Resident #1's nursing progress note dated 09/25/25 at 12:14 AM by LVN E reflected Cefazolin was not administered due to Awaiting med from pharmacy and PICC line to be replaced.-Record review of Resident #1's nursing progress note by LVN E dated 09/25/25 at 3:55 AM reflected the infusion company was contacted to schedule PICC replacement. -Record review of Resident #1's nursing progress note by LVN D on 09/25/25 at 9:15 AM reflected the PICC line was in place and an x-ray confirmed placement. -Record review of Resident #1's nursing progress note by LVN D on 09/25/25 reflected the Cefazolin was not administered due to Waiting on pharmacy. Record review of hospital records dated 09/25/25 reflected Resident #1's principal admission diagnosis was upper GI bleed and aspiration pneumonia and her hospital labs revealed her white cell blood count was 14.4. At her time of hospital discharge, the documentation reflected she had an unsteady gait, high fall risk and weakness and was confined to a bed, was unable to get up from bed without assistance, unable to ambulate and unable or sit in a chair or a wheelchair. During the hospital stay, documentation reflected Resident #1 had her foley removed, however, she continued to retain urine so the foley was replaced. She was discharged to the facility with a new order for Pantoprazole 40 mg po twice a day for 8 weeks for reflux esophagitis. Record review of Resident #1's pertinent nursing progress notes after the hospital re-admission reflected:-WCRN B's nursing note on 10/03/25 at 11:20 AM reflected the resident pulled at the wound vac dressing and dislodged it and had no recall of doing it. It was replaced by WCRN B at that time. -WCRN B's nursing note dated 10/06/25 (recorded as a late entry) reflected, Wound vac dressing replaced at this time resident dislodged it.-LVN A's nursing note on 10/06/25 at 8:40 PM reflected, Resident pulled the IV pole down on her fall mat. She was in the fetal position at the FOB. Blood backed up into the infusion line and is now clotted, unable to flush. [MD C] notified via text, awaiting new orders.-LVN E's nursing note dated 10/07/25 at 12:01 AM reflected, N/O per MD C, D/C Cefazolin IV and start Bactrim DS po TID x 10days. Order entered, RP to be notified in AM. Flush orders D/C'd. No flush was done this shift d/t PICC line clotted.-Record review of Resident #1's nursing progress note dated 10/07/25 at 8:16 AM (recorded as a late entry) reflected, Wound vac replaced at this time resident pulled suction dome off.-ADON G's nursing note reflected Resident #1 had an unwitnessed fall in her room from a low bed and was discovered on the floor next to her bed. The progress note further reflected, Another resident alerted staff that resident was observed to be in the floor. Upon entering the room resident was next to bed already attempting to get back up and on knees next to w/c. Res unable to answer questions regarding intent. Res obs for injury, Neuro's initiated, VS stable. Denies any c/o pain. Res assisted w/ 2 assist up to w/c No Pain. Interventions noted to be in place prior to fall were a floor mat and low bed. Interventions initiated in response to the fall was documented as, 1 on 1 supervision. -Record review of Resident #1's neurological assessments reflected they were initiated and completed on 10/07/25 at 12:15 PM, 12:30 PM, 12:45 PM, 1:00 PM, 1:20 PM, 2:00 PM, 2:43 PM, 3:00 PM and 4:00 PM. There were no other neurological assessments documented for Resident #1 after 4:00 PM into the next day on 10/08/25. -Record review of a fall follow-up nursing progress note dated 10/07/25 at 6:00 PM by LVN A reflected Resident #1 appeared to be in no pain and interventions were a floor mat and low bed. -Record review of Resident #1's nursing progress note dated 10/07/25 by WCRN B at 9:43 PM reflected, Wet to dry dressing applied to right hip, resident has pulled wound vac dressing loose numerous times today.-Record review of Resident #1's nursing progress note dated 10/07/25 at 9:44 PM by LVN A (entered as a late entry) reflected, I spoke with [RP] earlier about resident pulling wound vac dressing off several times a day, I explained that she may not be appropriate for wound vac. She asked what she would be appropriate for, I told her a wound treatment that is recommended to be changed numerous times a day. She said then how will we pull the infection out, I told her that wound vacs don't pull infection out that they pull drainage out and help granulate the wound for healing.- Record review of Resident #1's Transfer Notification nursing note dated 10/08/25 at 1:27 PM by ADON G reflected the resident had a fall at the nurses station and hit her head. The fall caused an abrasion to the left side of the head. Resident #1 was noted to react to painful stimuli with any attempts to move her bilateral lower extremities and was bleeding. The nursing note further reflected, Resident was sitting in w/c at nurses station when staff heard her scream. She was noted to be standing up and attempting to walk. She lost balance and hit her head against the nurses station and landed on left side of body. No LOC noted and mentation remained at baseline. VS assessed. Neuros assessed. Attempted to locate wounds/injury. EMS called. [RP] notified.Interventions in place prior to fall: 1 on 1 supervision. An interview with Resident #1's RP on 10/15/25 at 2:02 PM revealed multiple areas of concerns:1) The RP stated she had been trying for days to get help with [Resident #1's] wound vac which had stopped working after discharge from the hospital. She called who she thought was the administrator on Friday 09/26/25 and told her the wound vac wasn't pulling anything out. She said the administrator told her to bring the wound vac back on Saturday 09/27/25 and the nurse on duty would exchange it. The RP described arriving at the facility with the wound vac in her hands. She said she walked straight to the medication cart because she saw the nurse standing there and explained that the vac had alarms and wasn't functioning. The RP stated the nurse told her to just leave it there and walked off. Nobody even looked at it, the RP said. Wanting to be sure someone was accountable, she went to the DON's office. The RP said she told him directly, I brought this because it's not working-[Resident #1] still needs wound suction. She stated the DON replied that it was not his department and advised her to leave it with the floor nurse. The RP said she never received any call-back, paperwork or update and that no one from management followed up that weekend. They acted like I was bothering them, she said. The RP said the wound vac sat silent for days and no changes were made to the plan or nurses' notes to address the failure. She also said she never saw anyone check the tubing or document wound measurements after readmission. The RP stated that on several visits she found [Resident #1] in poor condition, describing unclean wound care and neglected hygiene. The RP stated during one observation at the facility, Resident #1 was sitting in a wheelchair and her wound flap had stool and drainage stuck to it. She saw the wound vac was disconnected, the tubing coiled on the floor and the unit covered in dried fluid. 2) The RP also stated Resident #1's PICC line had not been flushed or used for several days and that the site dressing was black and crusted. She said staff gave oral antibiotics instead of IV doses and that the pills were large even though [Resident #1] was on a puree diet. The RP stated nursing staff told her the resident would be fine taking oral medication, but the RP was concerned she could not swallow them. The RP did not indicate that she observed the resident taking medications orally or observed her struggle, it was just a concern. 3) The RP said she believed [Resident #1's] reinfection and worsening condition resulted from the facility's failure to clean the wound, use the vac, and maintain IV therapy as ordered. 4) The RP stated she also discovered the PICC line unprotected and soiled after a fall that she had not been notified about. It was dirty and dried out-it hadn't been touched, she said. She said she alerted the nurse, who said they were short-staffed and would clean it later. The RP said no one checked vital signs or assessed the wound for hours afterward. She added that she repeatedly asked for the resident to be monitored more closely because she was weak and at risk for falls, but no supervision plan was implemented. 5) The RP stated Resident missed several IV antibiotic doses while at the facility. Nurses told her that the pharmacy had not send the antibiotics yet but a few days later, the RP said she found out the facility switched her to oral medication. The RP felt the facility made the choice without physician consultation or notice to the RP. They just said, 'We're giving her pills now,' the RP said. The RP said the large tablets were inappropriate for [Resident #1's] swallowing restrictions and that she witnessed coughing and choking during administration. She said she was never informed that IV therapy had been discontinued or that doses were missed.6) The RP stated she was never notified of major changes in condition or treatment. She said no one told her the wound vac had been removed, that the PICC line was no longer used, or that the resident had fallen. She learned about each incident only when she visited. No one ever called me-I just kept finding things on my own, she said. She described repeatedly calling the facility afterward and receiving inconsistent explanations. She stated on 10/08 after Resident #1's fall where she fractured her other hip, she called the DON because she was boiling mad and she ended up getting ADON G and told her all of the things going on with Resident #1 and her concerns. The RP stated ADON G suggested a care plan meeting. The RP stated, I was like why wasn't there a care plan meeting done from the very beginning? So much switching around and disorganization, you would think that bringing a new resident into the facility would have been the very first thing. 7) The RP then stated, [Resident #1] is going to die now. She has to go on hospice, the doctors cannot do anything else to treat her. I have no other options left. We are trying to get her some skilled days in this new facility to give one last chance to see if any sign of improvement but every doctor at [hospital] said unfortunately nothing more we can do, too much trauma from breaking right and left hip.GI issues and trauma to the head- there is nothing more we can do at this point and we strongly suggest hospice now. So I am trying to give her a couple more weeks (at the new SNF) to see. and then if not, I have no choice because she is so much pain, two broken hips, head trauma, internal bleeding. [Previous SNF] put the right foot in the grave and [current SNF] put the left. The RP stated ADO contacted her after the fall on 10/08/25 at 6:12 PM and she told the ADO everything that had happened, what was going on with wound vac, PICC not running and dirty and the infection in right hip, the left hip now broken. The RP stated, She (ADO)was speechless. She didn't say anything except I will have to get back to you. An interview with WCRN B on 10/15/25 at 11:51 AM revealed Resident #1 was the only resident in the facility who received wound vac therapy and required it applied to her right hip but she would not leave the wound vac on, dislodged and pulled it off daily. She stated within two days, Resident #1 was sent back to the hospital for a GI bleed and re-admitted on [DATE] but did not get the wound vac until the next day. WCRN-B stated she remembered because she had to change the wound vac dressing twice that day because it was dislodged and had peeled off. She said the tape used was very secure and wound vacs were supposed to stay in place for a number of days up to a week. WCRN-B stated Resident #1 would not just unhook the wound vac tubing, somehow the whole suction dome itself would be loose, so she had to patch and change it multiple times. WCRN-B stated when there was an order for a wound vac, there was an accompanying facility standing order that reflected if the wound vac dressing was dislodged, a wet to dry dressing (a type of wound dressing that consist of a moist layer of gauze or other material placed directly on the wound, followed by a dry layer to absorb drainage) could be used. She stated, As the wound care nurse, I can replace, but other staff cannot replace, that is why a wet to dry dressing is done when I am not here and it becomes dislodged. WCRN-B stated most of the nurses that worked at the facility knew how to work the wound vac machine but did not necessarily know how to do the dressing change. She stated the weekend supervisor, one other nurse and [RN F] knew how to do the dressing change. WCRN-B stated she did not know if nurses had been in-serviced on how to use a wound vac. She said the machine was rented and there was a QR code that the nurse could scan on the machine, And that is how I figured out how to work it. WCRN-B stated on 10/07/25 around 9:30 PM, she had already done a wound vac dressing change twice for Resident #1, At that point, I did a wet to dry and it was likely going to pull loose again. She said the wound vac dressing already had to be changed twice the day before and three times on the current day. The WCRN-B stated Resident #1's wound was on her right hop, had typical drainage moderate for a wound vac, nothing wrong with it, pink tissue, probably four centimeters deep. The WCRN-B said Resident #1's RP thought there were issues with the wound vac when the resident first admitted because when WCRN-B placed it on the resident, it would show numerous error messages and I would have to mess with it, I could not say for certain if it was because [Resident #1] had messed with or pulled on it, [Resident #1] was all over the place. WCRN -B stated the wound vac was difficult to change because Resident #1 did not want to roll onto her side and when staff moved her, the resident thought she was going to fall. WCRN-B also thought the tape used for the dressing may have itched which would cause Resident #1 to try and peel it off. She said Resident #1 grabbed at staff, their clothing and they would give her a fidget [NAME], but she was still very confused and had no recall. WCRN-B stated the wound vac was new when Resident #1 admitted and it was corporate staff who were in charge of providing them or a person from central supply. WCRN-B stated Resident #1 ended up going to the hospital right after she admitted for a GI bleed and she should have gone with a wet to dry dressing, But I guess the nurse was in a panic but she went with a wound vac, not the plug. So after we got it back (wound vac), the [RP] was saying there was an issue with it and she wanted a different one, that two doctors had tried it and it didn't work. And I was like how could they if they didn't have a plug for power? WCRN-B stated when Resident #1 re-admitted from the hospital, she placed the wound vac on her and it worked fine. WCRN-B stated she did not think Resident #1 needed a wound vac in her opinion and felt it did not stay on her long enough to know if it was working good. She said the way to know if there was good suction was if there were no error messages on the machine and when it was turned onto negative pressure, the foam hardened and became rigid. The WCRN-B stated she did initial measurements when Resident #1 admitted but not when she re-admitted on [DATE]. She said Resident #1 was not at the facility long enough the first time for the wound care doctor to see her and the second time, I was not clear if she had a follow up with the surgeon that did her surgery because if she did, she didn't need to see the wound doctor here. WCRN-B said the wound doctor that rounded at the facility came on Tuesdays but had not seen Resident #1 when she was at the facility on 10/07/25. Additionally, WCRN-B said she did not know if Resident #1 had a follow-up appointment to the surgeon but stated, Our wound doctor does not see residents still under the care of a surgeon. An interview with LVN D on 10/15/25 at 12:32 PM revealed Resident #1 pulled her wound vac dressing off frequently, even though she never saw her do it. She said Resident #1 also pulled at her catheter quite a bit and would itch around the area and felt it irritated her skin but she never saw her pull it out. She said at one point, Resident #1 did pull out her PICC line and it was replaced by the infusion company. LVN D stated she was able to get one dose of antibiotic medication through her PICC line and reached out to the doctor to see about an oral route because the resident wanted to pull at the line. LVN D stated, It made it hard because I would have to sit here and hold her hands so she didn't' mess with it. She said she would try to entertain Resident #1 and would sit her by the medication cart and talk to her. She said she did contact [MD C] to get an oral antibiotic approved. She stated Resident #1 would take oral medications much easier but she said she did not notify the RP of the order change. LVN D said the change of dose from IV to oral change happened before her shift started, but she was still responsible to call and order it from the pharmacy. LVN D stated the nurse who got the order change was responsible for calling the RP. She did not know who got the order change. LVN D stated if the RP had wanted to continue with a PICC line, they would have had to find an alternative way to find those doses and it would have been up to the facility and family. She stated the potential harm of not notifying family of changes in treatment, Issues could be any, I don't know, they could not agree maybe with what the facility was doing. LVN D denied having any issues with the PICC line. LVN D stated she was not qualified to change a sterile PICC line dressing. An interview with LVN A on 10/15/25 at 3:55 PM revealed the wound vac functioned as far as she knew and when she sent Resident #1 to the ER on her shift the day after her admission for vomiting, I accidentally let it (wound vac) go with her. But we got it back and everything was functioning properly. LVN A stated she was the charge nurse who did Resident #1's initial, sent her out on day two and did her subsequent re-admission. LVN A stated Resident #1 pulled out her PICC line when she initially admitted because it was observed on the floor, but no one saw the resident pull it out. LVN A said she examined the PICC line site area and it was fine. She did a dressing over it and notified the physician and the RP. LVN A did not recall any problems flushing the PICC line the first night, but on the second admission on [DATE], Resident #1 had removed the hub off the IV bag and it was on the floor. LVN A said she got another one and re-attached it but was unable to flush the line because i

Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accident hazards/supervision . The facility failed to implement and maintain 1:1 supervision for Resident #1 as was recommended by nursing management following a fall on 10/07/25. On 10/08/25, Resident #1 fell at the nurses' station while not under 1:1 supervision and sustained another fall, striking her head on the counter and fracturing her left hip. An IJ was identified on 10/17/25 at 11:48 AM. The IJ template was provided to the facility on [DATE] at 11:38 AM. While the IJ was removed on 10/18/25, the facility remained out of compliance at a scope of no actual harm and a severity level of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal and because all nursing staff had not been trained on fall and supervision protocols related to enhanced and 1:1 supervision needs of high-fall risk residents. This failure placed residents at risk for significant injury, hospitalization or death due to not having adequate supervision to prevent accidents. Findings included: Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year-old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnosis was sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others- ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no signs or symptoms of delirium and no negative mood issues. Resident #1 had no potential indicators of psychosis and no behavioral symptoms, no rejection of care issues and no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity. Resident #1 always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high risk medications: anticoagulant, antibiotic and anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline upon admission. Record review of Resident #1's care plan initiated 09/25/25 reflected E. Focus: The resident is risk for falls (Date Initiated: 10/08/25); Interventions/Tasks: 1) Anticipate and meet the resident's needs (Date Initiated: 10/08/25), 2) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Date Initiated: 10/08/25), 3) Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs (Date Initiated: 10/08/25), Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (Date Initiated: 10/08/25), Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (Date Initiated: 10/08/25), Keep furniture in locked position (Date Initiated: 10/08/25), Keep needed items, water, etc, in reach (Date Initiated: 10/08/25), Pt evaluate and treat as ordered or PRN (Date Initiated: 10/08/25), Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes (Date Initiated: 10/08/25), Staff x 2 to assist with transfers (Date Initiated: 10/08/25), The resident needs a safe environment (Date Initiated: 10/08/25), The resident needs activities that minimize the potential for falls while providing diversion and distraction (Date Initiated: 10/08/25). Record review of Resident #1's admission Nursing Note by LVN A dated 09/24/25 reflected she admitted at 6:00 PM with her responsible party from the hospital. The nurse recorded her vitals and noted Resident #1 had a hip fracture, a PICC line on the right upper extremity, an anticoagulant and antibiotic ordered. Resident #1 was documented as non-mobile/bedfast and could not bear weight, required one person assistance for bed mobility and two-person assist for transfers. Record review of Resident #1's Fall Risk Assessment completed dated 09/24/25 reflected a score of 11, which indicated she was a high-risk. Record review of Resident #1's Physical Therapy Evaluation and Plan of Treatment dated 10/03/25 reflected Resident #1 demonstrated significant bilateral lower extremity weakness, greater on the right side, with impaired coordination, poor balance and severely reduced safety awareness. The therapist documented that Resident #1's dynamic standing balance was poor, her gross motor coordination impaired and her cognition severely limited, with the resident rarely able to understand or express needs. She had a known history of falling with injury, having sustained a right femoral neck fracture on August 2025 and continued to report fear of falling and unsteadiness when standing or walking. Resident #1's prior level of function had been supervision or touching assistance for mobility, which indicated a measurable decline and increased dependence at the time of the evaluation. Physical therapy goals focused on restoring safe bed mobility, transfer and ambulation with contact-guard to stand-by assistance to prevent additional falls. The therapist documented Resident #1 was a high fall risk who required close supervision and skilled intervention, emphasizing that without consistent staff oversight and assistance, the resident was at risk for further decline, immobility and repeat injury. Record review of a nursing progress noted dated 10/07/25 at 12:15 PM by ADON G reflected Resident #1 had an unwitnessed fall in her room from a low bed and was discovered on the floor next to her bed. The progress note further reflected, Another resident alerted staff that resident was observed to be in the floor. Upon entering the room resident was next to bed already attempting to get back up and on knees next to w/c. Res unable to answer questions regarding intent. Res obs for injury, Neuro's initiated, VS stable. Denies any c/o pain. Res assisted w/ 2 assist up to w/c No Pain. Interventions noted to be in place prior to fall were a floor mat and low bed. Interventions initiated in response to the fall was documented as, 1 on 1 supervision. Record review of Resident #1's Transfer Notification nursing note dated 10/08/25 at 1:27 PM by ADON G reflected the resident had a fall at the nurses station and hit her head. The fall caused an abrasion to the left side of the head. Resident #1 was noted to react to painful stimuli with any attempts to move her bilateral lower extremities and was bleeding. The nursing note further reflected, Resident was sitting in w/c at nurses station when staff heard her scream. She was noted to be standing up and attempting to walk. She lost balance and hit her head against the nurses station and landed on the left side of body. No LOC noted and mentation remained at baseline. VS assessed. Neuros assessed. Attempted to located wounds/injury. EMS called. [RP] notified.Interventions in place prior to fall: 1 on 1 supervision. Review of the Resident #1's hospital records dated 10/09/25 reflected she admitted to the ER on [DATE] at 2:08 PM and had a 3cm deep laceration of the left occipital area (the smallest of the four brain lobes, located at the back of the head, and is primarily responsible for processing visual information)and a 10 cm surgical incision to the right hip that was dehisced with purulent discharge (means a surgical wound has opened up and is draining thick, pus-like fluid, which strongly indicates an infection) and packed with gauze, decreased range of motion, pain, tenderness noted in the left hip and she was not oriented and confused. The hospital documentation also reflected there was a PICC line to Resident #1's upper arm that appeared clotted and unable to be flushed. The hospital x-rays indicated Resident #1 had a left hip fracture and needed surgical repair. Resident #1 was then sent to her previous surgeon who did her right hip surgery at a higher level of care for orthopedics. An interview with the DOR on 10/15/25 at 11:26 AM revealed Resident #1was on physical and occupational therapy services and she did not have any balance or transfer ability, required constant redirection and could not follow instructions. The DOR stated the therapy department recommended the facility needed a 1:1 staff to sit with her and when that was recommended, typically the family would provide that individual, Because our facility is not equipped for that. If the family can't provide, I am not sure what we would do, probably recommend her go to a different facility. The DOR stated the facility did an intervention and use of call light, but the resident would not have been able know how to use it. The DOR stated she remembered after Resident #1 re-admitted from the hospital, I think she just crawled out of her wheelchair and fell and was sent due to pain. For therapy, the DOR said Resident #1 required one-step cues, had word salad and was not able to communicate or follow instructions. The DOR stated she evaluated her for the first time the second day of her admission, but Resident #1 had to be sent to the ER because she was vomiting black meaty substance. The DOR stated Resident #1 re-admitted on [DATE] and was a totally different person. For example, the first day the resident initially admitted , the DOR said she could not get her to open her eyes or lift her head off the bed. But when she came back from the hospital second time, the DOR said she was able to ask her how she was doing and the resident was more alert but still not able to hold a conversation. The DOR said Resident #1 used a wheelchair with maximum assistance and she thought the resident could take a few steps. The DOR stated, I don't think we got to a point where we tried to walk her. She would not sit still in her wheelchair and would climb over the footrests. The DOR stated Resident #1 came to the facility with an infected right hip wound from a recent surgery. She had a PICC line on her right bicep and pulled it out per clinical meeting report. The DOR said she did not know what the facility did about it, but she was sure they put it back in and wrapped it. She was not sure but felt the facility also had a 3rd party that could come and place one too. The DOR stated therapy saw Resident #1 for about a week and then she had a fall on 10/08/25 and that was when they found out she fractured her other hip. The DOR said they knew Resident #1 had a new hip fracture because the admissions coordinator was in contact with the hospital for updates. An interview with LVN D on 10/15/25 at 12:32 PM revealed Resident #1 did not fall on her shift. LVN D said when a resident fell, the nurse was supposed to look for injuries, notify the physician to see if the resident needed to be sent out based on vitals and injuries, then call the family and let them know. She said neurochecks got initiated right away and were done every 15 minutes for the first hour, then 30 minutes for an hour, then follow up for the next 72 hours. LVN D stated she did not assign a sitter to be with Resident #1 but did keep her by her out of caution in the hall or at the nurses' station. She said if therapy recommended a sitter for a resident for safety reasons, there were no actual sitters and she did not know what the protocol was for that. LVN D said no one told her Resident #1 needed a 1:1 staff, It was her behaviors, she would try to get up out of her wheelchair. LVN D stated for residents identified as a high fall risk, the professional expectation was to keep them entertained, distract them and keep them beside the staff and within eyesight. LVN D stated, I have 14 residents on the hall. It is not always possible to keep a resident with me when I have 14 other residents. An interview with CNA H on 10/15/25 at 1:02 PM revealed she spent one week working with Resident #1 and needed help with basically everything such as changing, feeding, dressing. She said Resident #1 could kind of bear weight with two people on each side but could not do anything for herself and could not walk and she had never seen the resident try to. CNA H stated after one of her falls, Resident #1 needed to be 1:1. She said the fall occurred after lunch, and she heard a noise and when she went out into the hall, Resident #1 was in the hall on the ground surrounded by ADON G and the activity director. CNA H said Resident #1 was bleeding from her head and her hip was in pain because she was squirming around and could not get comfortable. She said the fall happened around 1:00 PM after lunch. CNA H stated earlier that day, She was good, she was supposed to be one-on-one, so we tried to keep her in sight, nurse kept her when passing meds and rolling her with her and I had her with me during documentation on my hall. CNA H said, however, during lunch it was difficult because the staff had to pass trays and feed residents. CNA H stated, I gave her to [ADON G] and [WCRN B] and [ADON G] was feeding her and the new man in therapy took her to therapy and as far as I know she was brought back and that is when she fell. CNA H stated, We knew she needed a one-on-one, it was obvious because we couldn't leave her alone without her ripping her lines, not only that, she would try to stand up and she was a fall risk. CNA H said there was no staff to do 1:1 for residents at the facility. She stated, Like me, I am on the hall down there by myself. I have 13 residents on my hall. I have a nurse and we don't have a med aide. In the past, we have had a resident like that with 1:1 every shift, so what they did at first they would ask us to come in for an extra shift to do it, one resident I think the family or facility got a person from a company to come and sit with the resident. CNA H said she thought it would have been safer for Resident #1 to have 1:1 supervision, For us, it would have helped us, she was big, like she needed a lot of help all the time, watch her or else things like this would happen like the falling. CNA H said her outcome for residents that were a high-fall risk was for the charge nurses to let the CNAs know more information about the residents, Like wounds or injuries because sometimes we don't know anything until we go into provide care. An interview with Resident #1's RP on 10/15/25 at 2:02 PM revealed she repeatedly asked for the resident to be monitored more closely because she was weak and at risk for falls, but no supervision plan was implemented by the facility. An interview with LVN A on 10/15/25 at 3:55 PM revealed she worked with Resident #1 the day prior to her fall (10/07/25). She said she got up and walked out of bed. LVN A saw the resident at the door when she was passing meds. Then the next day when LVN A came for her next shift around 2:00 PM, she saw Resident #1 had to be babysat because she needed 1:1. LVN A said she believed Resident #1 needed a private sitter and it would have been the family's responsibility to provide one. LVN A stated, We don't have a memory care unit, especially on my hall because I am skilled nursing and I have 12 other people. So I parked my med cart by her and put her in a wheelchair in her doorway, and that is how I dealt with that. An interview with the ADO on 10/16/25 at 10:08 AM revealed she was notified that Resident #1 had a witnessed fall at the nurses' station and had a fractured left hip. She said the DON reported Resident #1's RP was upset so she wanted to call and talk with her. The ADO stated when she called, she stated, I heard the resident had a fracture and I was going through her chart and she has a lot going on. And then the [RP] let me have it. Told me how she believes we let her fall and break her hip. The ADO said she apologized and saw where the PICC line was clogged on 10/07/25, but the facility had contacted the physician and got an oral antibiotic, and no doses were missed. The ADON stated, That was my first concern since she did have an infection in her wound. The ADO then stated she notified the RP that an incident report to HHSC would be initiated for the fall with a major injury and the RP responded, 'You have plenty of time to falsify the chart. The ADO said fall risk interventions for Resident #1 were to be in a low bed and have a fall mat, keep her in her wheelchair at the nurses' station so she could be supervised. The ADO said when a resident fell, it would be reviewed during the clinical stand-up meetings the next day when they pull a risk management report and the IDT would discuss interventions. She said if a resident was recommended for 1:1 supervision by the DOR, that should be communicated during the stand up meetings. She felt it was a teaching point she needed to do with the DOR because she came from assisted living and We don't provide 1:1 care, we provide assistance as we can accommodate. Anytime a resident is on 1:1, we will bring in extra staff, but then we have to look for a higher level of care because it is not sustainable. She said the facility could utilize department heads or CNAs who wanted extra money, but it was typically done for residents with behaviors or at the end of life and could be done on a case by case basis. The ADO did not know if Resident #1's RP was offered the option to hire a private sitter. She said the company could pay for a sitter because at one of the other facilities the company owned, she heard of them paying for up to four months for a 1:1 staff for a resident with behaviors. The ADO stated, We made sure the fall mat was in place and increased supervision.We spoke to the nursing staff about clear communication between shifts. An interview with the VPCO on 10/16/25 at 10:40 AM revealed Resident #1 had two falls, the first one in her room where the intervention was increased supervision which escalated to 1:1, then the second fall occurred where she was sent to the hospital. She stated when 1:1 supervision was initiated; a staff member would be assigned to the resident at all times in arm's distance or less than six feet way. She did not know if the facility assignment sheets reflected the need for 1:1 coverage for Resident #1. She said change of shift communication was the monitoring system that ensured enhanced supervision remained in place one ordered. She also stated neurochecks documentation was completed following both falls through 10/08/25. The VPCO stated there had been no revision of facility policies or clarifications to policies as a result of the incidents with Resident #1. She felt the staff responded appropriately when Resident #1 had a fall. An interview with the DON on 10/16/25 at 1:00 PM revealed he was at the facility the day Resident #1 fell but did not witness anything. He said when he observed Resident #1, she was in pain and confused and the nurse who witnessed the fall reported she hit her head so she was sent to the ER for further evaluation. The DON stated Resident #1 had also fallen the day before but he did not know if it was witnessed or unwitnessed. He said when neurochecks were completed for a resident, they get the initial set every 15 minutes for the first hour, then every 30 minutes for two hours, then every hour for four hours and then continue to monitor every shift for 72 hours. He said the nurses did neurochecks to assess if the resident had any drastic changes in their blood pressure or any altered level of consciousness. The nurse then had to complete a progress note generated through PCC where they filled in the required information. The DON said neuros still had to be done during sleeping hours. An interview with ADON G on 10/16/25 at 1:20 PM revealed Resident #1's updated fall interventions were initiated when she completed the incident report, but she had made the mistake of clicking the wrong intervention. She stated Resident #1 should have had increased supervision, not 1:1. ADON G stated increased supervision meant more frequently monitored. She said if a resident needed 1:1 supervision, I've never done it, it is just reported with all the staff and they are made aware that the resident would require it. ADON G stated neurochecks were completed for Resident #1 post the first fall on 10/07/25. ADON G stated she witnessed Resident #1's fall on 10/08/25. She was at the med cat on the hall talking to a nurse and Resident #1 was at the nurses' station facing towards her in the hall. ADON G saw Resident #1 in the wheelchair start to stand up. As ADON G started to move towards her, Resident #1 turned around and fell. ADON G stated there was one nurse (LVN J) who had his back to her and he was documenting at the nurses' station and there were no other staff present. ADON G stated she assessed Resident #1 because she saw her hit her head on the counter of the nurses' station. When she and the other staff tried to turn Resident #1, she yelled out so they left her there, placed gauze in the vicinity of the wound and assessed her through neuros and vitals. She said Resident #1 never lost mentation, stayed at her baseline and was pleasant. 911 was called and she was sent out for evaluation. ADON G stated she did not think Resident #1 had been placed with LVN J specifically, I think he was just there, She said prior to the fall, she had assisted Resident #1 with her lunch and then therapy had taken her over and then I believe therapy left her at the nurses' station but I don't know. ADON G stated she did not know if Resident #1's fall could have been prevented. She stated, She could have fallen with 1:1, she was restless. Review of LVN J's witness statement of Resident #1's fall dated 10/09/25 reflected in full, I was sitting at the nurses station documenting and did not see the resident fall down. [Resident #1] fell behind me. An interview with the ADO on 10/17/25 at 9:26 AM revealed when she looked at Resident #1's incident report related to the first fall, she saw that ADON G made the intervention choice of 1:1 supervision on the report. The ADON stated she wanted to know if the CNAs knew Resident #1 was on 1:1 supervision so she called them and they did know she needed 1:1. The ADO stated the company's policy on what 1:1 supervision entailed was not specific on distance or location but she thought there was a policy for it. The ADO stated once ADON G made the new fall intervention of 1:1, her assumption was ADON G then told the staff Resident #1's new supervision requirements as well as during the stand up meeting where she thought the DOR was made aware of it. The ADO stated a physician's order was not required to initiate 1:1 supervision with a resident. The ADO stated Resident #1's care plan was updated with fall interventions but she did not know if the 1:1 supervision need was documented. An interview with MD C was attempted and unsuccessful on 10/17/25 9:55 AM. Review of the facility's policy titled, Fall Policy (not dated) reflected, The Fall risk Assessment Tool will be completed at admission and after each fall occurrence. The assessment should be completed by reviewing the resident's medical history, social history and functional status. Information may be obtained by reviewing current medical records, interview with resident/family or conference with the interdisciplinary team members. The assessment tool should be scored and interventions implemented as indicated.Appropriate interventions will be addressed immediately on the interdisciplinary plan of care, reassessment will occur after each fall. Interventions will be resident centered.The nurse will complete an event fall nurses note after each fall. Falls resulting in serious injury will be reported to the DON and/or Administrator. The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as required. An Immediate Threat (IT) was identified on 10/17/25 related to Resident #1's lack of supervision and subsequent fall. The ADO was notified and provided with the IT template on 10/17/25 11:38 AM. A Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 10/17/25 at 3:31 PM and reflected: Problem: F689 Accident and HazardsInterventions:1. Resident #1 no longer resides in the facility as of 10/8/25.2. No residents in the facility currently require 1:1 monitoring as of 10/17/25.3. All residents in the facility had fall risk assessments completed by the Regional Compliance Nurse, ADON, and Charge Nurses. Completed 10/17/25.4. All fall risk care plans were reviewed by Compliance Nurse, ADON and Charge Nurses for appropriate interventions. Completion date 10/17/25.5. The compliance Nurse in-serviced the Administrator DON and ADON 1:1 on the following in-services. Completed 10/17/25.a. Abuse and Neglect Policy- including failure to provide fall risk interventions such as increased supervision could result in subsequent falls with injury to residents. The failure to provide supervision could be considered neglect.b. Fall Prevention Policy- to include appropriate interventions such as increased supervision to prevent falls.c. 1:1 Monitoring- when a resident is placed on 1:1 monitoring, an assigned staff member will be scheduled to monitor the resident to prevent accidents and hazards. Monitoring will be scheduled for all shifts and recorded on a monitoring form. 1:1 monitoring orders will be put in EMAR and discontinued upon physician order.d. Documentation Policy- When a resident is placed on increased supervision, the charge will be documented in the chart via fall note or progress note every shift for a minimum of 72hrs. Monitoring will be scheduled for all shifts and recorded on a monitoring form. 6. The medical director was notified of the immediate threat by the Administrator on 10/17/25.7. An ADHOC QAPI meeting will be conducted with the IDT to include the Medical Director to discuss the immediate threat citation and plan of removal. Completed 10/17/25.In-servicesAll staff were in-serviced by the Regional Compliance Nurse, DON, and ADON on the following in-services below. All staff not present will be in-serviced prior to the start of their shifts. All PRN will be in-serviced prior to their next scheduled shift. All new hires will be in-services during facility orientation. All agency staff will be in-serviced prior to their assignment if utilized. Completed 10/17/25a. Abuse and Neglect Policy- including failure to provide fall risk interventions such as increased supervision could result in subsequent falls with injury to residents. The failure to provide supervision could be considered neglect.b. Fall Prevention Policy- to include appropriate interventions such as increased supervision to prevent falls.c. 1:1 Monitoring- when a resident is placed on 1:1 monitoring, an assigned staff member will be scheduled to monitor the resident to prevent accidents and hazards. Monitoring will be scheduled for all shifts and recorded on a monitoring form. 1:1 monitoring will not be removed unless ordered by a Physician.d. Documentation Policy- When a resident is placed on increased supervision, the charge will be documented in the chart via fall note or progress note every shift for minimum of 72hrs. Monitoring will be scheduled for all shifts and recorded on a monitoring form. Monitoring the Plan of Removal implementation occurred on 10/17/25 through 10/18/25. Facility monitoring activities included review of 24-hour reports, risk management logs, fall documentation and supervision assignment sheets to identify any additional incidents involving falls, inadequate supervision or lapses in 1:1 monitoring. No resident had fallen and there were currently no residents on enhanced supervision. A 100% sweep was conducted for all residents to re-assess their fall risk score and ensure it was accurate and care plan were reviewed for accuracy. Staff competency validations and in-service training records were reviewed for nursing staff related to fall protocols and supervision needs. 16 nursing and management staff were interviewed across all shifts (ADO, LVN A, WCRN B, RN F, ADON G, VPCO, MD K, LVN L, RN M, RN O, LVN R, LVN S, CNA T, CNA U, RN V, RNC) and demonstrated awareness of the facility's protocols related to increased supervision, fall prevention and documentation expectations. All staff monitored demonstrated understanding of when to initiated and document 1:1 supervision and how to escalate concerns to the licensed nurse of DON. A monitoring interview with ADON G was conducted on 10/18/25 at 12:26 PM regarding fall protocols and supervision for high-risk residents following the IT determination. ADON G stated the facility's policy when a resident fell was to update the care plan at the time of the incident and new interventions were expected to be documented by the end of the shift, and the charge nurse was responsible for those updates with the assistance of MDS staff if available. ADON G said that waiting 24-hours to update the care plan was too long, because documentation should reflect current risks and care being provided. She stated, If we are adjusting interventions, we need to record that. ADON G stated the charge nurse was responsible for initiating the care plan revision following a fall and that CNAs were notified of new interventions verbally before the plan was formally updated. She said nursing management verified that neurochecks and supervision interventions were implemented by reviewing them daily. ADON G stated after the IT was identified, the facility began daily review of critical systems-including abuse/neglect, wound vac, PICC line care, catheter management, change of condition and fall prevention and staff received in-servicing on each of those areas. She described new expectations for enhanced supervision and 1:1 monitoring. ADON G stated orders for 1:1 supervision were going to be issued by the physician, documented on paper forms and the charge nurse was to ensure follow through. The ADON said for a change in condition and neurochecks, nurses were expected to notify the physician immediately, initiate the fall protocol and record all neurological checks per policy. She said that supervision and neurochecks compliance was now being verified daily through management review. An interview on 10/18/25 at 12:43 PM with the ADO revealed care plans were to be reviewed and updated during the same shift when an event or change in condition occurred. She said, During our daily morning stand-up, risk management is reviewed by the IDT team and interventions and updates are made at that time. The care plan revision-we can do them then. That's the gold standard. She clarified that charge nurses were responsible for initiating revisions and could place immediate interventions after a fall or change in condition. The ADO stated, If I am the DON, you're calling me after a resident falls, and I expect you to interve

Based on interview and record review, the facility failed to ensure that residents are free of any significant medication errors for one (Resident #1) of five residents reviewed for pharmacy services. The facility did not administer Resident #1's prescribed IV antibiotics through her PICC line or her ordered Lovenox injections following a surgery for a right hip fracture sustained from a prior fall. This failure placed residents at risk of not receiving medications as prescribed in order to meet residents needs.Findings included:Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others- ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no signs or symptoms of delirium and no negative mood issues. Resident #1 had no potential indicators of psychosis and no behavioral symptoms, no rejection of care issues and no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity. Resident #1 always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high risk medications: anticoagulant, antibiotic and anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline upon admission. Record review of Resident #1's care plan initiated 09/25/25 and revised 10/08/25 reflected the following care areas: Focus: The resident is on anticoagulant therapy. (Date Initiated: 10/08/25)- Interventions/Tasks: Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (Date Initiated: 10/08/2025) Focus: The resident has Intravenous (IV) Access. (Date Initiated: 10/08/25)-Interventions/Tasks: 1) Administer IV fluids as ordered (Date Initiated: 10/08/25), Administer IV medications as ordered (Date Initiated: 10/08/25), Check dressing at site daily. Monitor for signs and symptoms of infection, Drainage, Inflammation, Swelling, Redness, Warmth. if present notify the physician (Date Initiated: 10/08/25), Flush the ports/lines as ordered (Date Initiated: 10/08/25), If Tegaderm ( a transparent medical dressing used to cover and protect wound sites); change dressing every 7 days and prn-If gauze dressing change every 48 hours (Date Initiated: 10/08/2025), the resident has PICC line IV access (Date Initiated: 10/08/2025). Record review of a facility admission Alert-Communication Alert for Approved Admissions for Resident #1 dated 09/24/25 at 3:36 PM and signed by LVN Q reflected the resident's ETA was 6:00 PM and her special requirements included ADL assist, IV meds and wounds. Equipment needs included PICC line and wound vac. A copy of the hospital discharge orders were included in the alert and reflected Resident #1 had Cefazolin (Ancef) 2 grams intravenously every eight hours and Ertapenem one gram intravenously every day. Record review of Resident #1's order summary reflected the prescribing physician was MD C: -Cefazolin Sodium Injection Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection, R hip (Start Date 09/25/25); -Ertapenem Sodium Solution Reconstituted 1 GM Use 1 gram intravenously every 24 hours for infection, R hip for 1 Day (start date 09/24/25) and Lovenox Injection Solution Prefilled Syringe 40 MG/0.4ML (Enoxaparin Sodium) Inject 40 mg subcutaneously one time a day for R hip fracture related to for 28 Days (Start Date 09/25/25. Record review of Resident #1's September 2025 MAR reflected she was not administered her three antibiotic doses of Cefazolin on 09/25/25, her second day of admission at 1:00 AM (refused) and 9:00 AM (refused). Record review of Resident #1's October 2025 medication administration record reflected that she was not administered her prescribed anticoagulant Lovenox or her IV antibiotic Cefazolin on 10/03/25. A nursing note by LVN D reflected, Resident refused, swatting at nurse. Further review reflected Lovenox was also not administered on 10/06/25, 10/07/25 and 10/08/25 with refusals again documented by LVN D on the MAR. Additionally, the oral antibiotic Bactrim, ordered by MD C on 10/06/25 was not administered until the morning of 10/07/25). Record review of a Resident #1's pertinent nursing progress notes reflected: -09/24/25 at 6:00 PM by LVN A (admission nursing note) documented she admitted at 6:00 PM with her responsible party from the hospital. The nurse recorded her vitals and noted Resident #1 had a hip fracture, a PICC line on the right upper extremity, an anticoagulant and antibiotic ordered.-09/24/25 at 8:46 PM LVN A documented Ertapenem was not administered due to awaiting delivery from pharmacy.- 09/25/25 at 12:14 AM LVN E documented Cefazolin was not administered due to Awaiting med from pharmacy and PICC line to be replaced.-09/25/25 at 3:55 AM by LVN E documented the infusion company was contacted to schedule PICC replacement.-09/25/25 at 8:45 AM by LVN D documented, Nurse called [RP] or consent for insertion for new PICC line after resident pulled it out last night. Resident's [RP] consented to insertion of PICC line.-09/25/25 at 9:15 AM by LVN D documented Resident #1's PICC line was in place and an x-ray confirmed placement.-09/25/25 at 10:06 AM by LVN D documented the Cefazolin was not administered due to Waiting on pharmacy.-09/25/25 by LVN A-Transfer Notification Progress Note by LVN A on reflected, [Resident #1] was transferred to a hospital on [DATE] 8:30 PM related to vomiting black, meaty smelling emesis x 2. This is intended to serve as notice of an emergency transfer. A nursing note dated 10/02/25 by LVN A reflected Resident #1 re-admitted with a diagnosis of an upper GI bleed, was non-mobile and bedfast, was not oriented or alert and had memory impairment and she had a foley catheter in place.-10/06/25 at 8:13 AM-e-MAR administration note by LVN D reflected the Lovenox injection was not administered due to Resident swatting at nurses hands and jumping.-10/06/25 at 8:40 PM LVN A documented, Resident pulled the IV pole down on her fall mat. She was in the fetal position at the FOB. Blood backed up into the infusion line and is now clotted, unable to flush. [MD C] notified via text, awaiting new orders.-10/07/25 at 12:01 AM LVN E documented, N/O per [MD C], D/C Cefazolin IV and start Bactrim DS po TID x 10 days. Order entered, RP to be notified in AM. Flush orders D/C'd. No flush was done this shift d/t PICC line clotted. All needs anticipated and met by staff. Resting in bed with eyes closed. No s/s of distress/discomfort noted. Bed low, call light in reach, fall mat in place.-10/07/25 at 9:43 AM by LVN D documented Lovenox was not administered because, Resident pushed nurse's hands away and refused injection.-10/08/25 at 8:59 AM by LVN D reflected the resident refused the medication administration for Lovenox. An interview with LVN D on 10/15/25 at 12:32 PM revealed Resident #1 did pull out her PICC line and it was replaced by the infusion company during her stay. LVN D stated she was able to get one dose of antibiotic medication through her PICC line and reached out to the doctor to see about an oral route because the resident wanted to pull at the line. LVN D stated, It made it hard because I would have to sit here and hold her hands so she didn't' mess with it. She said she would try to entertain Resident #1 and would sit her by the medication cart and talk to her. She said she did contact [MD C] to get an oral antibiotic approved. She stated Resident #1 would take oral medications much easier but she said she did not notify the RP of the order change. LVN D said the change of dose from IV to oral change happened before her shift started, but she was still responsible to call and order it from the pharmacy. LVN D stated if the RP had wanted to continue with a PICC line, they would have had to find an alternative way to find those doses and it would have been up to the facility and family. She stated the potential harm of not notifying family for changes in treatment, Issues could be any, I don't know, they could not agree maybe with what the facility was doing. LVN D denied having any issues with the PICC line. LVN D stated she was not qualified to change a sterile PICC line dressing. An interview with LVN A on 10/15/25 at 3:55 PM revealed Resident #1 pulled out her PICC line when she initially admitted because it was observed on the floor, but no one saw the resident pull it out. LVN A said she examined the PICC line site area and it was fine. She did a dressing over it and notified the physician and the RP. LVN A did not recall any problems flushing the PICC line the first night, but on the day of the second re-admission on [DATE], Resident #1 had removed the hub off the IV bag and it was on the floor. LVN A said she got another one and re-attached it was unable to flush the line because it was clotted in the PICC line due to being exposed to air. LVN A said Resident #1 had an arterial venous two port. She said she notified MD C and the RP but was not sure which infusion company to call due to recent contract changes and the recent facility company changeover. She said, They (unknown) were going to talk to administration and it was taken out of my hands. LVN A said she worked with Resident #1 the next evening and her PICC line was working. LVN A said she did not know what happened with the PICC line, I didn't get a good report on that, but it was functioning. LVN A stated she knew Resident #1 had missed some IV antibiotics on her shift during her stay but could not remember what day she missed them and surmised it was the first night of admission because that was the night the PICC line had to be replaced. She said she was not able to administer the IV meds the next day either but she thought Resident #1 only missed one dose. LVN A stated there was no alternative when a when a resident pulled out a PICC line, and it wasn't until the second removal that MD C ordered an oral antibiotic to cover the resident until they tried to figure out what we were going to do. She further stated, We just didn't know what to do with her honestly. I don't think we were the right place for her, she needed memory care. An interview with the VPCO on 10/16/25 at 10:40 AM revealed Resident #1's IV antibiotic was changed to oral because she was pulling at other things and the thought process by the charge nurse was to change the order to po to make it easier to administer. She stated, I believe the physician obliged and switched to Bactrim. The VPCO stated there was one dose that the charge nurse was unable to administer for IV antibiotics from the 10/06/25 into 10/07/25 due to the line being clotted, so an oral order was obtained and the new antibiotic was administered the morning of 10/07/25. She said the facility had an e-kit and that was where Resident #1 got her initial dose of Bactrim. An interview with the DON on 10/16/25 at 1:00 PM revealed he spoke to Resident #1's RP on 10/07/25 and she had expressed concerns about the PICC line and how insurance was not going to pay it she was on oral antibiotics and not IV. The DON told her he did not have an answer for her and told her she could still get coverage for the wound vac and we would figure out about the PICC line. The DON stated the RP asked about IV antibiotics and he informed her Resident #1 had been switched over and she was on Bactrim now. The DON said he did not know if Resident #1 missed any doses during that time. The DON stated he was not notified when Resident #1's PICC line was clogged but was told the next day the nurse had to get an order to change it to oral antibiotic. The DON stated there was a way to get a PICC line going again, there was a company the facility used that came out and unclogged them. The DON stated, I don't believe they came out and unclogged it. I don't know why. It was already discontinued and pulled out by the time I got to work so I didn't assess it. The DON stated his expectation was it a PICC line was clogged, the charge nurse should have called the infusion company to get a new one placed. He did not know if the infusion company worked 24/7, but thought if the line came out at night, they would come out the next morning. If it could not get replaced quickly, the DON said the nurse would notify the doctor. He did not know what the charge nurse did that night the PICC line was clogged. An interview with ADON G on 10/16/25 at 1:20 PM revealed she did not know Resident #1's PICC line was clotted or the IV meds had been stopped until she got to work the morning after and got shift report. ADON G said she was told the night nurse had received an order from MD C for an oral antibiotic. She did not know if that nurse had contacted the infusion company to come and replace the line before requesting the route change and she did not know if the charge nurse assessed the PICC line post-removal. An interview with MD C was attempted and unsuccessful on 10/17/25 9:55 AM. An interview with the C-VP on 10/17/25 at 12:59 PM revealed Resident #1 was unable to receive one of her antibiotic medications three times via her PICC line and MD C was notified and the PICC line was removed. She did not know if MD C was told the IV antibiotic was unable to be administered per order. A follow up interview with LVN A on 10/17/25 at 2:05 PM revealed there was a pharmacy the facility used that did deliveries three times a day. She did not know the exact times, but thought one was at dinner time and one at midnight. LVN A said if a resident admitted in the later part of the afternoon, there may be some medications that would come in that night, but by the daytime next shift, they would all be coming in. She stated the latest she could order medications for a new admission from the pharmacy was around 5 or 6 pm for the midnight delivery. LVN A stated missing three doses of IV antibiotics, the facility should already be talking about a backup plan with the doctor. LVN A stated the problem with missing three doses of IV abx was you will not have a decrease in bacteria, there would be an increase and flora will start growing. LVN A stated she was open to oral antibiotics due to the problems with the PICC line and Resident #1 fiddling with the lines and unwrapping the bandaging. LVN A stated the facility tried long-sleeved shirts and [MD C] went with the flow of whatever we had to do. Regarding the Lovenox, LVN A stated she tried to contact the doctor and get a hold order which was done typically when residents refused it. She stated Lovenox was an anticoagulant and was prescribed because Resident #1 had a hip fracture and was prone to a DVT, which could travel to her lungs and give her a pulmonary embolism. She said anyone who had a surgery was prone to that, especially leg surgery. She stated she never administered Resident #1 Lovenox because it was a morning medication and she did not work that shift. If a resident refused a high risk medication, LVN A said the protocol was by the second refusal, she would notify the doctor. LVN A stated there was a problem the night she tried to fax MD C about Resident #1's PICC line being clotted and she did not start the oral Bactrim that night as a result. She stated the order would have been sent to the pharmacy and she felt like she probably gave it from the e-kit but could not remember. An interview with MD K on 10/17/25 at 1:00 PM revealed he was the medical director for the facility and he and MD C had the bulk of the residents as patients. He stated he did not know Resident #1 and had never seen her as she was not assigned as his patient. However, as the medical director, MD K stated if a resident had an IV antibiotic medication upon admission and the facility knew they would not be able to obtain and give the medication when it is to be given, they really did not have a choice but to send the resident back to the hospital. MD K stated, I've told them before to send them back and infuse as an outpatient in the emergency room at the hospital until we get the antibiotic delivered, then they can come back. He stated some residents were more critical than others, for example, if the resident admitted with sepsis, They certainly need to have it [IV abx] continued. MD K stated missing three doses of an antibiotic medication was too many and he thought that the facility's contracted pharmacy would have provisions to do stat deliveries. MD K stated Lovenox was an anticoagulant that was used to help prevent DVT for surgery and it should be readily available. He stated if a resident was refusing Lovenox, the simple solution would be to change the medication to Xarelto or Eliquis, both oral medications, But they need to call the doctor to consult us if the resident is refusing. MD K stated a lot depended on the patient and the shape they were in, if they were bedfast or had any peripheral edema. An interview with LVN L on 10/18/25 at 11:33 AM revealed when a new resident admitted with time-sensitive mediations, as the admission nurse he would write the order, enter it into the computer, call the pharmacy and verify if they received the order. Then if it was an antibiotic and the facility did not have it, he would check the e-kit to see if it was available and call the pharmacy to get the code. He stated if he needed a medication and it was not in the e-kit, he would call the pharmacy and let the doctor know the resident did not receive the dose and hope it came in the next day. LVN stated he did not administer Resident #1's Lovenox because it was a morning medication. He said Lovenox was quite important because it was a blood thinner, One degree lower than heparin. An interview with RN M on 10/18/25 at 11:49 AM revealed when a new resident admitted , the charge nurse who admitted the resident could always check the e-kit and see if the medication was available, if not, then call the pharmacy and see how soon they could get it to the facility. Then the physician should be contacted to see if he wanted an alternative medication or did he want to wait. RN M did not know what antibiotics were kept in the e-kit and said pharmacy usually came around 8-10 PM on her shift. RN M stated with the anticoagulant Lovenox, she did not work with Resident #1 but knew the medication was used to keep blood clots from forming and was usually used after surgeries. An interview with ADON G on 10/18/25 at 12:26 PM revealed when a resident was newly admitted , orders were to be entered timely and as ordered. For medications not in stock, ADON G said they worked with what they had in stock and usually did not get advanced notice of orders coming in with new admissions. She stated that the nursing management, which included herself and the DON, reviewed admissions, verified orders had been processed and the pharmacy had been contacted. ADON G stated there was no formalized tracking log showing timeliness for medication deliveries or stat medications. She said her expectation would be for the nurse to notify the physician immediately if a medication was unavailable or delayed, ADON G stated communication between nurses, pharmacy and provider was expected to be verbal and immediate for critical admissions and that if issues arose, They would be expected to call the pharmacy and discuss any issues. An interview on 10/18/25 at 12:43 PM with the ADO revealed that upon a resident's admission, nursing staff immediately entered new orders into e-MAR, which transmitted directly to the pharmacy. She stated, When they arrive to the facility, we enter meds into e-MAR which immediately sends the order to the pharmacy. She said the pharmacy delivered in the evenings, but if not, the facility had an extensive e-kit available to utilize. The ADO described that for time-sensitive medications, such as IV antibiotics or anticoagulants, if the item was not in stock and needed urgently, We can call pharmacy and they can STAT a med out. We also have contracts with local pharmacies so it can be 'hot-shotted' to the facility. The ADO said the administrative nurses (ADONs and DON) were supposed to verify admissions and ensure the pharmacy had been contacted. The ADO stated, It's a team effort to admit a resident, but med entry is a priority after initial assessment because we know we have to get them in-it's an immediate process. The ADO stated for monitoring missed or delayed medications, We review our dashboard. The DON and I review it during morning meeting, and if we see any missed meds, then we address it right then. She added that if a PICC line was dislodged or malfunctioned, nurses were expected to notify the physician immediately, obtain orders for replacement and if necessary, Call immediately to our PICC line vendor, and if it will delay to next dose, then get alternate med or hold if not critical for the resident. Review of the facility's e-Kit medication list provided by the ADO on 10/18/25 reflected there were two tablets available for Sulfamethoxazole/Trimethoprim (also known as Bactrim) . The e-kit inventory list also reflected the facility had emergency access in the kit to the blood thinners Eliquis, Xarelto and Warfarin as well as alternative oral antibiotics of Amoxicillin-Clavulanate, Ceftriaxone, Ciprofloxacin and Azithromycin. Review of the facility's policy titled, Medication Administration and General Guidelines (dated March 2025) reflected, Medications are administered in accordance with written orders of the attending physician.10. Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time.Unless otherwise specified by the physician, routine medications are administered according to the established administration schedule for the facility.12. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled.The physician must be notified when a dose of medication has not been given.

Based on interview and record review, the facility failed to make prompt efforts to resolve grievances regarding the resident's care and treatment for one (Resident #1) of five residents reviewed for care concerns. The facility failed to document a grievance, respond and follow through on Resident #1's RP concerns when she voiced them to multiple management staff about poor nursing care and issues with her PICC line, wound vac, antibiotic medication and falls. This failure could place residents at risk for harm by allowing ongoing care concerns-including missed medications, PICC line and wound care issues, to go unaddressed, delaying necessary interventions and oversight.Findings included:Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others and the MDS reflected ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity (the parts of the body from the hips down to the feet, including the thighs, knees, legs, ankles, and toes). Resident #1 was always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high risk medications: anticoagulant, antibiotic and anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline upon admission. Record review of Resident #1's care plan initiated 09/25/25 and revised 10/08/25 reflected the following care areas: A. Focus: Resident has a surgical site to: R hip with negative pressure wound therapy to right hip at -125 continuously (a treatment that uses suction to aid healing in chronic or non-healing wounds), B. Focus: The resident is on anticoagulant therapy. (Date Initiated: 10/08/25), C. Focus: The resident has Hip Fracture. (Date Initiated: 10/08/25), D. Focus: The resident has Intravenous (IV) Access. (Date Initiated: 10/08/25) and E. Focus: The resident is risk for falls (Date Initiated: 10/08/25).Record review of Resident #1's medication order summary for September 2025 and October 2025 reflected she required extensive wound care and IV therapy following her readmission with a right hip infection and sepsis. Resident #1's physician orders directed that the surgical wound to the right hip be cleaned with normal saline, packed with gauze and draped daily with a negative pressure wound therapy vac (a medical device that uses suction to promote wound healing) to remain in place continuously at 125 mmHg. Resident #1 also had standing orders for IV antibiotics, including Cefazolin every eight hours and Bactrim DS for bacterial infection and Lovenox for prevention of blood clots. Additional physician instructions included daily saline flushes to maintain IV line patency (the state of being open or unobstructed, allowing for the free flow of fluids, air, or blood) and wet-to-moist dressing changes if the vac became dislodged.An interview with Resident #1's RP on 10/15/25 at 2:02 PM revealed she was not notified when the resident's PICC line was not able to be flushed and used to administer the IV medications. She stated when she saw the PICC line tubing, it appeared black and crusted, and she became aware of the issue only during a visit. The RP also stated staff did not contact her to inform her that Resident #1's IV antibiotic therapy had been stopped and change to oral medications until after the change was made. The RP stated the nursing staff told her she would be fine taking oral medications, but she was concerned Resident #1 would not be able to swallow them safety due to being on a pureed diet. The RP further stated she was not notified when the resident's urinary catheter immediately after it had been dislodged and not replaced. The RP stated she expected to be informed of any change to IV therapy or catheter status, as she was the responsible party for the resident's care decisions. Review of the facility's documented grievances from 09/25/25 through 10/18/25 revealed none for Resident #1. An interview with the ADO on 10/16/25 at 10:08 AM revealed she was notified that Resident #1 had a witnessed fall at the nurses' station and had a fractured left hip. She said the DON reported Resident #1's RP was upset so she wanted to call and talk with her. The ADO stated on the call she told the RP, I heard the resident had a fracture and I was going through her chart and she has a lot going on. And then the [RP] let me have it. Told me how she believes we had put a broken wound vac on her, clogged PICC line and she was not getting IV antibiotics and we let her fall and break her hip. The ADO said she apologized and saw where the PICC line was clogged on 10/07/25, but the facility had contacted the physician and got an oral antibiotic and no doses were missed. The ADO then stated she notified the RP that an incident report to HHSC would be initiated for the fall with a major injury and the RP responded, 'You have plenty of time to falsify the chart. An interview with the VPCO on 10/16/25 at 10:40 AM revealed she was not aware about the issues with Resident #1's PICC line, wound vac or two falls until after Resident #1 was transferred to the hospital on [DATE] The VPCO said the ADO had notified her Resident #1's RP was upset after the second fall on 10/08/25 and the facility had initiated a self-reported incident to HHSC based upon the concern that she was upset with care. She thought the ADO also completed a grievance for the RP's care concerns and they were important because any concerns needed to be addressed appropriately and reported back to whoever made the concern.An interview with the DON on 10/16/25 at 1:00 PM revealed he spoke to Resident #1's RP on 10/07/25 and she had expressed concerns about the PICC line and how insurance was not going to pay if she was on oral antibiotics and not IV. The DON told her he did not have an answer for her and told her she could still get coverage for the wound vac and we would figure out about the PICC line. The DON stated the RP asked about IV antibiotics and he informed her Resident #1 had been switched over and she was on Bactrim now. The DON said he did not know if Resident #1 missed any doses during that time. The DON stated he did not complete a grievance form related to Resident #1's RP concerns but he told her he would talk to the insurance company about the coverage for oral versus IV medication. He also said the RP had concerns about the wound vac but when he saw it on Resident #1, it was working and told her it was on her now. The DON stated looking back, he probably could have done a grievance for the RP's concerns, but when he was talking to her, he thought they were on the same page and she was satisfied with their conversation. An interview with ADON G on 10/18/25 at 12:26 PM revealed she had recently learned that any staff member could enter a grievance into their e-charting system. She said once those were entered online, they were routed to the appropriate department for review. ADON G stated, It takes the burden off one person. Typically, our social worker did them before. ADON G added that when families made multiple or serious complaints, the determination whether it qualified as a formal grievance depended on the grievance and what was involved. If the issue was complex, ADON G said it could require additional resources and multiple department members. ADON G stated staff were expected to check with a supervisor or management before deciding not to initiate a grievance so they could ensure every concern was documented.A follow up interview with the ADO on 10/18/25 at 12:43 PM revealed when a resident had a concern or complaint, she expected anyone with PCC access (a cloud-based software platform for the senior and long-term care industry that helps manage electronic health records, billing, and resident engagement)-with the exception of CNAs-to open a grievance and start it. The ADO stated grievances were entered electronically and management reviewed them daily and during monthly QAPI meetings. The ADO stated her expectation was that any concern was documented, and If there's frustration, anger, or genuine concerns-it's a grievance. She said if a resident/family member were emotionally attached or anxious about a concern, that was when staff should recognize something is wrong and initiate a grievance. The ADO said when Resident #1's RP raised concerns about wound care and supervision, the ADO and the DON reviewed documentation and determined whether a grievance was warranted. The ADO stated, Looking through the chart, it looked like communication had been happening through the PICC line issue and staff were documenting. I didn't think a grievance was needed at that time, but I did a self-report for the fall with injury and the RP's concern that the facility was not caring for her [Resident #1]. The ADO confirmed that a self-report was submitted to the State and that she and a corporate clinical RN investigated it that same evening and discovered Resident #1's PICC line was clotted and that an oral antibiotic was subsequently obtained. She stated she saw that the resident's antibiotics were changed and the wound vac was replaced. When asked if the RP's concerns fit the definition of a grievance under the facility's policy, the ADO replied, Personally, I do not, because we addressed it with a self-report.Review of the facility's Provider Investigation Report to HHSC for Resident #1 dated 10/08/25 reflected the incident category listed was Other and the description of the allegation by the ADO who reported it was, Resident stood up at the nurses station and fell. The self-report did not indicate any concerns of abuse/neglect of Resident #1 or concerns that the RP felt the resident's care was a concern.Review of the facility's policy titled, Grievances (Revised 11/02/2016) reflected, The resident has a right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have.Procedure:.2. The grievance official of this facility if the administrator or their designee. 3. The grievance official will: Oversee the grievance process, Receive and track grievances to their conclusion.Issue written grievance decisions to the resident.6. All written grievances decisions will include: 1) The date the grievance was received, 2) A summary statement of the resident's grievance, 3) The steps taken to investigate the grievance, 4) A summary of the pertinent findings or conclusions regarding the resident's concern(s), 5) A statement as to whether the grievance was confirmed or not confirmed, 6) Any corrective action taken or to be taken by the facility as a result of the grievance and 7) The date the written decision was issued.

Based on interview and record review, the facility failed to notify the resident's physician and responsible party of a significant change in condition for one (Resident #1) of five residents reviewed for notification of changes. 1. The facility failed to notify Resident #1's responsible party when the resident's urinary catheter was found removed with the balloon intact, when the resident's antibiotic therapy was modified from being administered through a PICC line to oral and when the PICC line became clogged and was unable to be used.2. The facility failed to notify the physician of Resident #1's missed IV antibiotic doses and refused medications. This failure could place residents at risk for delayed medical evaluation, treatment, lack of timely involvement by the responsible party in resident care decisions and the potential for worsening of the resident's condition.Findings included: Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year-old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction) and direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others and the MDS reflected ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity. Resident #1 was always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high-risk medications: anticoagulant, antibiotic and anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline (a long peripheral IV catheter inserted into a vein in the arm, with its tip terminating in the arm, not reaching the heart) upon admission. Record review of Resident #1's care plan initiated 09/25/25 and revised 10/08/25 reflected the following care areas all initiated on 10/08/25: A. Focus: Resident has a surgical site to: R hip with negative pressure wound therapy to right hip at -125 continuously. Res frequently pulls wound vac off despite education. May use wet to moist dressing if dislodged; B. Focus: The resident is on anticoagulant therapy.D. Focus: The resident has Intravenous (IV) Access. Resident #1's care plan did not reflect the use of a catheter. Record review of pertinent nursing notes related to Resident #1's change of condition reflected:-A nursing progress note by LVN A on 09/24/25 at 9:45 PM reflected Resident #1 pulled her PICC line out on her own and it was found next to her bed with no active bleeding at insertion site. There was no documentation to reflect the RP was notified. -A nursing progress note by LVN D the next morning on 09/25/25 at 8:45 AM reflected Nurse called [RP] for consent for insertion for new PICC line after resident pulled it out last night. Resident's [RP] consented to insertion of PICC line.-A nursing progress note by LVN A on 10/03/25 at 9:45 AM reflected Resident #1 pulled out her foley catheter (a thin, flexible tube inserted into the urethra to drain urine from the bladder) with the balloon (anchors the catheter in the bladder, preventing it from slipping out) intact and was found by the CNAs. Nurse assessment reflected there was no bleeding or obvious trauma noted. There was no documentation to reflect the RP was notified of the removal.-A nursing progress note by LVN A on 10/06/25 at 8:40 PM reflected, Resident pulled the IV pole down on her fall mat. She was in the fetal position at the FOB. Blood backed up into the infusion line (An IV line is used to deliver medicines, fluids, blood products, or nutrition into a patient's bloodstream) and is now clotted, unable to flush. [MD C] notified via text, awaiting new orders. There was no documentation to reflect the RP was notified of the PICC line issue.-A nursing progress note by LVN E dated 10/07/25 at 12:01 AM reflected, N/O per [MD C], D/C Cefazolin IV and start Bactrim DS po TID x 10days. Order entered, RP to be notified in AM. Flush orders D/C'd. No flush was done this shift d/t PICC line clotted. There was no documentation the RP was notified at the time of the new order implementation. An interview with Resident #1's RP on 10/15/25 at 2:02 PM revealed Resident #1 missed several IV antibiotic doses while at the facility. She said the nurses told her the pharmacy had not sent the medication yet. The RP said days later, the facility switched Resident #1 to oral antibiotic medication without notice to the RP. She stated, They just said, 'We're giving her pills now'. The RP also stated she was never informed that IV therapy had been discontinued or that doses were missed. The RP stated she was never notified of major changes in Resident #1's condition or treatment. The RP said no one told her the PICC line was no longer going to be used. The RP stated she learned about each incident only when she visited. The RP stated she was never told Resident #1 pulled out her catheter. She stated she remembered visiting the resident and did not see the catheter bag hanging on the side of her bed or wheelchair. The RP stated she did not recall any concerns being voiced by the hospital post-fall on 10/08/25 of any vaginal trauma. An interview with LVN D on 10/15/25 at 12:32 PM revealed Resident #1 pulled at her catheter quite a bit and would itch around the area and LVN D felt it irritated the resident's skin, but she never saw her pull it out. She said at one point, Resident #1 did pull out her PICC line and it was replaced by the infusion company. LVN D stated she was able to get one dose of antibiotic medication through her PICC line and reached out to the doctor to see about an oral route because the resident wanted to pull at the line. She said she did contact [MD C] to get an oral antibiotic approved. LVN D stated Resident #1 would take oral medications much easier but she did not notify the RP of the order change. LVN D said the change of dose from IV to oral happened before her shift started, but she was still responsible to call and order it from the pharmacy. LVN D stated the nurse who got the order change was responsible for calling the RP. She did not know who got the order change. LVN D stated if the RP had wanted to continue with a PICC line, they would have had to find an alternative way to find those doses and it would have been up to the facility and family. She stated the potential harm of not notifying family for changes in treatment, Issues could be any, I don't know, they could not agree maybe with what the facility was doing. An interview with LVN A on 10/15/25 at 3:55 PM revealed she provided antibiotics though Resident #1's IV but did not provide wound care. She stated the wound vac functioned as far as she knew and when she sent Resident #1 to the ER on her shift the day after her admission for vomiting, I accidentally let it (wound vac) go with her. But we got it back and everything was functioning properly. LVN A stated she was the charge nurse who did Resident #1's initial admission and sent her out on day two (09/25/25) and did her subsequent re-admission on [DATE]. LVN A stated Resident #1 pulled out her PICC line when she initially admitted because it was observed on the floor, but no one saw the resident pull it out. LVN A said she examined the PICC line site area and it was fine. She did a dressing over it and notified the physician and the RP . LVN A did not recall any problems flushing the PICC line the first night, but on the second admission on [DATE], Resident #1 had removed the hub off the IV bag and it was on the floor. LVN A said she got another one and re-attached it but was unable to flush the line because it was clotted in the PICC line due to being exposed to air and she notified MD C and the RP. LVN A stated she knew Resident #1 had missed some IV antibiotics on her shift during her stay but could not remember what day she missed them and surmised it was the first night of admission because that was the night the PICC line had to be replaced. She said she was not able to administer the IV meds the next day either but she thought Resident #1 only missed one dose. LVN A stated Resident #1 did have a catheter and pulled it out, but she was not sure when and thought it was night two of admission. LVN A stated a CNA notified her the catheter was found on the floor. When she went to assess, she saw the catheter with a 10-cc [NAME] intact (a flexible tube-foley catheter, that is inserted into the bladder to drain urine with the 10-cc referring to the balloon's capacity of 10 cubic centimeters or milliliters) had been removed. LVN A stated, She ripped it out. She said Resident #1 showed no pain and there was no blood. LVN A said she notified MD C and nursing administration, assessed and placed Resident #1 in a brief and got her cleaned up. LVN A stated the potential harm of pulling out a catheter, I mean anything pulled out the size of a straw there could be internal trauma. I think it was a 22 French (a large-diameter urinary catheter used in specific situations where a larger size is needed to prevent blockage. The 22 French refers to the catheter's external diameter, which is approximately 7.3 mm). She stated the catheter removal happened at the end of her shift, so it was turned over to the night shift. LVN A said she did not consider the catheter removal to be a change in condition. LVN A stated, In hindsight, [RP] should have been notified by the nursing staff. I gave report the next shift, it had just happened. LVN A said the event happened on her shift and she should have been the nurse to notify the RP about it. An interview with the ADO on 10/16/25 at 10:08 AM revealed she was notified that Resident #1 had a witnessed fall on 10/08/25 at the nurses' station and had a fractured left hip. She said the DON reported Resident #1's RP was upset so she wanted to call and talk with her. The ADO stated when she called, she stated, I heard the resident had a fracture and I was going through her chart and she has a lot going on. And then the [RP] let me have it. Told me how she believes we had put a broken wound vac on her, clogged PICC line and she was not getting IV antibiotics and we let her fall and break her hip. The ADO said she apologized and saw where the PICC line was clogged on 10/07/25, but the facility had contacted the physician and got an oral antibiotic and no doses were missed. The ADO said she did verify via Resident #1's chart that, She declined so much and I don't think it mattered what lines she had, she would have pulled on any of them due to her dementia and it was a sad situation. The ADO stated maybe Resident #1's RP was not contacted about the catheter removal because the nurse did not think there was a medical change of condition. She stated, If it happens on your shift, you own it. The oncoming nurse isn't responsible because they weren't there. An interview with the VPCO on 10/16/25 at 10:40 AM revealed when she reviewed Resident #1's nursing documentation and chart, she did not see where the RP was notified of the catheter removal. An interview with the DON on 10/16/25 at 1:00 PM revealed he had heard Resident #1's catheter had been pulled out and the RP should have been notified by the nurse on the hall at the time. He stated it was important because we always want to keep families up to date with any changes. Review of the facility's policy titled, Notifying the Physician of Change in Status (revised 03/11/2013) reflected, The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilized the INTERACT tool, 'Change in Condition-When to Notify the MD/NP/PA' to review resident conditions and guide the nurse when to notify he physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work Day notification of the physician.5) The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. 7) The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's order and the resident's status and response to interventions.

Based on interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement with a licensed pharmacy in a timely manner and that drugs are administered as ordered by the physician for one (Resident #1) of five residents reviewed for pharmacy services. The facility did not administer Resident #1's prescribed IV antibiotics through her PICC line or her ordered Lovenox injections following a surgery for a right hip fracture sustained from a prior fall. The facility also failed to ensure these medications were obtained from the pharmacy and available for timely administration as ordered by the physician. This failure placed residents at risk of not receiving medications as prescribed in order to meet residents needs.Findings included:Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others- ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no signs or symptoms of delirium and no negative mood issues. Resident #1 had no potential indicators of psychosis and no behavioral symptoms, no rejection of care issues and no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity. Resident #1 always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Resident #1 was at risk of developing pressure ulcers/injuries and had one surgical wound that required surgical wound care. Resident #1 was administered the following high risk medications: anticoagulant, antibiotic and anticonvulsant. Resident #1 required a special treatment/procedure/program which included IV antibiotic administration via a midline upon admission. Record review of Resident #1's care plan initiated 09/25/25 and revised 10/08/25 reflected the following care areas: Focus: The resident is on anticoagulant therapy. (Date Initiated: 10/08/25)- Interventions/Tasks: Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (Date Initiated: 10/08/2025) Focus: The resident has Intravenous (IV) Access. (Date Initiated: 10/08/25)-Interventions/Tasks: 1) Administer IV fluids as ordered (Date Initiated: 10/08/25), Administer IV medications as ordered (Date Initiated: 10/08/25), Check dressing at site daily. Monitor for signs and symptoms of infection, Drainage, Inflammation, Swelling, Redness, Warmth. if present notify the physician (Date Initiated: 10/08/25), Flush the ports/lines as ordered (Date Initiated: 10/08/25), If Tegaderm ( a transparent medical dressing used to cover and protect wound sites); change dressing every 7 days and prn-If gauze dressing change every 48 hours (Date Initiated: 10/08/2025), the resident has PICC line IV access (Date Initiated: 10/08/2025). Record review of a facility admission Alert-Communication Alert for Approved Admissions for Resident #1 dated 09/24/25 at 3:36 PM and signed by LVN Q reflected the resident's ETA was 6:00 PM and her special requirements included ADL assist, IV meds and wounds. Equipment needs included PICC line and wound vac. A copy of the hospital discharge orders were included in the alert and reflected Resident #1 had Cefazolin (Ancef) 2 grams intravenously every eight hours and Ertapenem one gram intravenously every day. Record review of Resident #1's order summary reflected the prescribing physician was MD C: -Cefazolin Sodium Injection Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection, R hip (Start Date 09/25/25); -Ertapenem Sodium Solution Reconstituted 1 GM Use 1 gram intravenously every 24 hours for infection, R hip for 1 Day (start date 09/24/25) and Lovenox Injection Solution Prefilled Syringe 40 MG/0.4ML (Enoxaparin Sodium) Inject 40 mg subcutaneously one time a day for R hip fracture related to for 28 Days (Start Date 09/25/25. Record review of Resident #1's September 2025 MAR reflected she was not administered her three antibiotic doses of Cefazolin on 09/25/25, her second day of admission at 1:00 AM (refused) and 9:00 AM (refused). Record review of Resident #1's October 2025 medication administration record reflected that she was not administered her prescribed anticoagulant Lovenox or her IV antibiotic Cefazolin on 10/03/25. A nursing note by LVN D reflected, Resident refused, swatting at nurse. Further review reflected Lovenox was also not administered on 10/06/25, 10/07/25 and 10/08/25 with refusals again documented by LVN D on the MAR. Additionally, the oral antibiotic Bactrim, ordered by MD C on 10/06/25 was not administered until the morning of 10/07/25). Record review of a Resident #1's pertinent nursing progress notes reflected: -09/24/25 at 6:00 PM by LVN A (admission nursing note) documented she admitted at 6:00 PM with her responsible party from the hospital. The nurse recorded her vitals and noted Resident #1 had a hip fracture, a PICC line on the right upper extremity, an anticoagulant and antibiotic ordered.-09/24/25 at 8:46 PM LVN A documented Ertapenem was not administered due to awaiting delivery from pharmacy.- 09/25/25 at 12:14 AM LVN E documented Cefazolin was not administered due to Awaiting med from pharmacy and PICC line to be replaced.-09/25/25 at 3:55 AM by LVN E documented the infusion company was contacted to schedule PICC replacement.-09/25/25 at 8:45 AM by LVN D documented, Nurse called [RP] or consent for insertion for new PICC line after resident pulled it out last night. Resident's [RP] consented to insertion of PICC line.-09/25/25 at 9:15 AM by LVN D documented Resident #1's PICC line was in place and an x-ray confirmed placement.-09/25/25 at 10:06 AM by LVN D documented the Cefazolin was not administered due to Waiting on pharmacy.-09/25/25 by LVN A-Transfer Notification Progress Note by LVN A on reflected, [Resident #1] was transferred to a hospital on [DATE] 8:30 PM related to vomiting black, meaty smelling emesis x 2. This is intended to serve as notice of an emergency transfer. A nursing note dated 10/02/25 by LVN A reflected Resident #1 re-admitted with a diagnosis of an upper GI bleed, was non-mobile and bedfast, was not oriented or alert and had memory impairment and she had a foley catheter in place.-10/06/25 at 8:13 AM-e-MAR administration note by LVN D reflected the Lovenox injection was not administered due to Resident swatting at nurses hands and jumping.-10/06/25 at 8:40 PM LVN A documented, Resident pulled the IV pole down on her fall mat. She was in the fetal position at the FOB. Blood backed up into the infusion line and is now clotted, unable to flush. [MD C] notified via text, awaiting new orders.-10/07/25 at 12:01 AM LVN E documented, N/O per [MD C], D/C Cefazolin IV and start Bactrim DS po TID x 10 days. Order entered, RP to be notified in AM. Flush orders D/C'd. No flush was done this shift d/t PICC line clotted. All needs anticipated and met by staff. Resting in bed with eyes closed. No s/s of distress/discomfort noted. Bed low, call light in reach, fall mat in place.-10/07/25 at 9:43 AM by LVN D documented Lovenox was not administered because, Resident pushed nurse's hands away and refused injection.-10/08/25 at 8:59 AM by LVN D reflected the resident refused the medication administration for Lovenox. An interview with LVN D on 10/15/25 at 12:32 PM revealed Resident #1 did pull out her PICC line and it was replaced by the infusion company during her stay. LVN D stated she was able to get one dose of antibiotic medication through her PICC line and reached out to the doctor to see about an oral route because the resident wanted to pull at the line. LVN D stated, It made it hard because I would have to sit here and hold her hands so she didn't' mess with it. She said she would try to entertain Resident #1 and would sit her by the medication cart and talk to her. She said she did contact [MD C] to get an oral antibiotic approved. She stated Resident #1 would take oral medications much easier but she said she did not notify the RP of the order change. LVN D said the change of dose from IV to oral change happened before her shift started, but she was still responsible to call and order it from the pharmacy. LVN D stated if the RP had wanted to continue with a PICC line, they would have had to find an alternative way to find those doses and it would have been up to the facility and family. She stated the potential harm of not notifying family for changes in treatment, Issues could be any, I don't know, they could not agree maybe with what the facility was doing. LVN D denied having any issues with the PICC line. LVN D stated she was not qualified to change a sterile PICC line dressing. An interview with LVN A on 10/15/25 at 3:55 PM revealed Resident #1 pulled out her PICC line when she initially admitted because it was observed on the floor, but no one saw the resident pull it out. LVN A said she examined the PICC line site area and it was fine. She did a dressing over it and notified the physician and the RP. LVN A did not recall any problems flushing the PICC line the first night, but on the day of the second re-admission on [DATE], Resident #1 had removed the hub off the IV bag and it was on the floor. LVN A said she got another one and re-attached it was unable to flush the line because it was clotted in the PICC line due to being exposed to air. LVN A said Resident #1 had an arterial venous two port. She said she notified MD C and the RP but was not sure which infusion company to call due to recent contract changes and the recent facility company changeover. She said, They (unknown) were going to talk to administration and it was taken out of my hands. LVN A said she worked with Resident #1 the next evening and her PICC line was working. LVN A said she did not know what happened with the PICC line, I didn't get a good report on that, but it was functioning. LVN A stated she knew Resident #1 had missed some IV antibiotics on her shift during her stay but could not remember what day she missed them and surmised it was the first night of admission because that was the night the PICC line had to be replaced. She said she was not able to administer the IV meds the next day either but she thought Resident #1 only missed one dose. LVN A stated there was no alternative when a when a resident pulled out a PICC line, and it wasn't until the second removal that MD C ordered an oral antibiotic to cover the resident until they tried to figure out what we were going to do. She further stated, We just didn't know what to do with her honestly. I don't think we were the right place for her, she needed memory care. An interview with the VPCO on 10/16/25 at 10:40 AM revealed Resident #1's IV antibiotic was changed to oral because she was pulling at other things and the thought process by the charge nurse was to change the order to po to make it easier to administer. She stated, I believe the physician obliged and switched to Bactrim. The VPCO stated there was one dose that the charge nurse was unable to administer for IV antibiotics from the 10/06/25 into 10/07/25 due to the line being clotted, so an oral order was obtained and the new antibiotic was administered the morning of 10/07/25. She said the facility had an e-kit and that was where Resident #1 got her initial dose of Bactrim. An interview with the DON on 10/16/25 at 1:00 PM revealed he spoke to Resident #1's RP on 10/07/25 and she had expressed concerns about the PICC line and how insurance was not going to pay it she was on oral antibiotics and not IV. The DON told her he did not have an answer for her and told her she could still get coverage for the wound vac and we would figure out about the PICC line. The DON stated the RP asked about IV antibiotics and he informed her Resident #1 had been switched over and she was on Bactrim now. The DON said he did not know if Resident #1 missed any doses during that time. The DON stated he was not notified when Resident #1's PICC line was clogged but was told the next day the nurse had to get an order to change it to oral antibiotic. The DON stated there was a way to get a PICC line going again, there was a company the facility used that came out and unclogged them. The DON stated, I don't believe they came out and unclogged it. I don't know why. It was already discontinued and pulled out by the time I got to work so I didn't assess it. The DON stated his expectation was it a PICC line was clogged, the charge nurse should have called the infusion company to get a new one placed. He did not know if the infusion company worked 24/7, but thought if the line came out at night, they would come out the next morning. If it could not get replaced quickly, the DON said the nurse would notify the doctor. He did not know what the charge nurse did that night the PICC line was clogged. An interview with ADON G on 10/16/25 at 1:20 PM revealed she did not know Resident #1's PICC line was clotted or the IV meds had been stopped until she got to work the morning after and got shift report. ADON G said she was told the night nurse had received an order from MD C for an oral antibiotic. She did not know if that nurse had contacted the infusion company to come and replace the line before requesting the route change and she did not know if the charge nurse assessed the PICC line post-removal. An interview with MD C was attempted and unsuccessful on 10/17/25 9:55 AM. An interview with the C-VP on 10/17/25 at 12:59 PM revealed Resident #1 was unable to receive one of her antibiotic medications three times via her PICC line and MD C was notified and the PICC line was removed. She did not know if MD C was told the IV antibiotic was unable to be administered per order. A follow up interview with LVN A on 10/17/25 at 2:05 PM revealed there was a pharmacy the facility used that did deliveries three times a day. She did not know the exact times, but thought one was at dinner time and one at midnight. LVN A said if a resident admitted in the later part of the afternoon, there may be some medications that would come in that night, but by the daytime next shift, they would all be coming in. She stated the latest she could order medications for a new admission from the pharmacy was around 5 or 6 pm for the midnight delivery. LVN A stated missing three doses of IV antibiotics, the facility should already be talking about a backup plan with the doctor. LVN A stated the problem with missing three doses of IV abx was you will not have a decrease in bacteria, there would be an increase and flora will start growing. LVN A stated she was open to oral antibiotics due to the problems with the PICC line and Resident #1 fiddling with the lines and unwrapping the bandaging. LVN A stated the facility tried long-sleeved shirts and [MD C] went with the flow of whatever we had to do. Regarding the Lovenox, LVN A stated she tried to contact the doctor and get a hold order which was done typically when residents refused it. She stated Lovenox was an anticoagulant and was prescribed because Resident #1 had a hip fracture and was prone to a DVT, which could travel to her lungs and give her a pulmonary embolism. She said anyone who had a surgery was prone to that, especially leg surgery. She stated she never administered Resident #1 Lovenox because it was a morning medication and she did not work that shift. If a resident refused a high risk medication, LVN A said the protocol was by the second refusal, she would notify the doctor. LVN A stated there was a problem the night she tried to fax MD C about Resident #1's PICC line being clotted and she did not start the oral Bactrim that night as a result. She stated the order would have been sent to the pharmacy and she felt like she probably gave it from the e-kit but could not remember. An interview with MD K on 10/17/25 at 1:00 PM revealed he was the medical director for the facility and he and MD C had the bulk of the residents as patients. He stated he did not know Resident #1 and had never seen her as she was not assigned as his patient. However, as the medical director, MD K stated if a resident had an IV antibiotic medication upon admission and the facility knew they would not be able to obtain and give the medication when it is to be given, they really did not have a choice but to send the resident back to the hospital. MD K stated, I've told them before to send them back and infuse as an outpatient in the emergency room at the hospital until we get the antibiotic delivered, then they can come back. He stated some residents were more critical than others, for example, if the resident admitted with sepsis, They certainly need to have it [IV abx] continued. MD K stated missing three doses of an antibiotic medication was too many and he thought that the facility's contracted pharmacy would have provisions to do stat deliveries. MD K stated Lovenox was an anticoagulant that was used to help prevent DVT for surgery and it should be readily available. He stated if a resident was refusing Lovenox, the simple solution would be to change the medication to Xarelto or Eliquis, both oral medications, But they need to call the doctor to consult us if the resident is refusing. MD K stated a lot depended on the patient and the shape they were in, if they were bedfast or had any peripheral edema. An interview with LVN L on 10/18/25 at 11:33 AM revealed when a new resident admitted with time-sensitive mediations, as the admission nurse he would write the order, enter it into the computer, call the pharmacy and verify if they received the order. Then if it was an antibiotic and the facility did not have it, he would check the e-kit to see if it was available and call the pharmacy to get the code. He stated if he needed a medication and it was not in the e-kit, he would call the pharmacy and let the doctor know the resident did not receive the dose and hope it came in the next day. LVN stated he did not administer Resident #1's Lovenox because it was a morning medication. He said Lovenox was quite important because it was a blood thinner, One degree lower than heparin. An interview with RN M on 10/18/25 at 11:49 AM revealed when a new resident admitted , the charge nurse who admitted the resident could always check the e-kit and see if the medication was available, if not, then call the pharmacy and see how soon they could get it to the facility. Then the physician should be contacted to see if he wanted an alternative medication or did he want to wait. RN M did not know what antibiotics were kept in the e-kit and said pharmacy usually came around 8-10 PM on her shift. RN M stated with the anticoagulant Lovenox, she did not work with Resident #1 but knew the medication was used to keep blood clots from forming and was usually used after surgeries. An interview with ADON G on 10/18/25 at 12:26 PM revealed when a resident was newly admitted , orders were to be entered timely and as ordered. For medications not in stock, ADON G said they worked with what they had in stock and usually did not get advanced notice of orders coming in with new admissions. She stated that the nursing management, which included herself and the DON, reviewed admissions, verified orders had been processed and the pharmacy had been contacted. ADON G stated there was no formalized tracking log showing timeliness for medication deliveries or stat medications. She said her expectation would be for the nurse to notify the physician immediately if a medication was unavailable or delayed, ADON G stated communication between nurses, pharmacy and provider was expected to be verbal and immediate for critical admissions and that if issues arose, They would be expected to call the pharmacy and discuss any issues. An interview on 10/18/25 at 12:43 PM with the ADO revealed that upon a resident's admission, nursing staff immediately entered new orders into e-MAR, which transmitted directly to the pharmacy. She stated, When they arrive to the facility, we enter meds into e-MAR which immediately sends the order to the pharmacy. She said the pharmacy delivered in the evenings, but if not, the facility had an extensive e-kit available to utilize. The ADO described that for time-sensitive medications, such as IV antibiotics or anticoagulants, if the item was not in stock and needed urgently, We can call pharmacy and they can STAT a med out. We also have contracts with local pharmacies so it can be 'hot-shotted' to the facility. The ADO said the administrative nurses (ADONs and DON) were supposed to verify admissions and ensure the pharmacy had been contacted. The ADO stated, It's a team effort to admit a resident, but med entry is a priority after initial assessment because we know we have to get them in-it's an immediate process. The ADO stated for monitoring missed or delayed medications, We review our dashboard. The DON and I review it during morning meeting, and if we see any missed meds, then we address it right then. She added that if a PICC line was dislodged or malfunctioned, nurses were expected to notify the physician immediately, obtain orders for replacement and if necessary, Call immediately to our PICC line vendor, and if it will delay to next dose, then get alternate med or hold if not critical for the resident. Review of the facility's e-Kit medication list provided by the ADO on 10/18/25 reflected there were two tablets available for Sulfamethoxazole/Trimethoprim (also known as Bactrim) . The e-kit inventory list also reflected the facility had emergency access in the kit to the blood thinners Eliquis, Xarelto and Warfarin as well as alternative oral antibiotics of Amoxicillin-Clavulanate, Ceftriaxone, Ciprofloxacin and Azithromycin. Review of the facility's policy titled, Medication Administration and General Guidelines (dated March 2025) reflected, Medications are administered in accordance with written orders of the attending physician.10. Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time.Unless otherwise specified by the physician, routine medications are administered according to the established administration schedule for the facility.12. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled.The physician must be notified when a dose of medication has not been given.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time-frames to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for care plans. The facility failed to revise Resident #1's care plan after she fell on [DATE] to include updated fall prevention interventions and nursing management's identification of 1:1 supervision needs. The failure could place residents at risk for additional falls and injury by delaying the implementation and documentation of required supervision and safety interventions following a known fall event. Findings included: Record review of Resident #1's Face Sheet dated 10/15/25 reflected she was a [AGE] year old female who admitted to the facility initially on 09/24/25 and re-admitted on [DATE] after a hospital stay and was discharged back to the hospital on [DATE]. Resident #1's principal admission diagnoses were sepsis (life-threatening condition that occurs when the body's immune system releases harmful chemicals in response to an infection) and a closed fracture of the right femur (broken thighbone). Secondary diagnoses included dementia with behavioral disturbance (a condition characterized by cognitive decline accompanied by significant changes in behavior and personality), Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), acute postprocedural pain (pain that occurs after a medical or surgical procedure and lasts for up to 3 months), inflammatory polyneuropathies (a group of disorders characterized by inflammation of the peripheral nerves, leading to damage and dysfunction), direct infection of right hip in infectious and parasitic diseases. Record review of Resident #1's admission MDS assessment dated [DATE] reflected no BIMS score/assessment or cognitive pattern review. Resident #1 was sometimes understood by others and the MDS reflected ability is limited to making concrete requests and responds adequately to simple, direct communication only. Resident #1 had no wandering behaviors. Resident #1 was dependent on staff for ADLS and used a manual wheelchair for mobility. Resident #1 had range of motion impairment on one side of her lower extremity (the parts of the body from the hips down to the feet, including the thighs, knees, legs, ankles, and toes). Resident #1 was always incontinent of bowel and bladder and her primary reason for admission reflected, hip and knee replacement. Resident #1 had a fall prior to admission that resulted in a fracture. Additionally, Resident #1 had a major surgery within 100 days prior to admission that required SNF care. Record review of Resident #1's Fall Risk Assessment completed dated 09/24/25 reflected a score of 11, which indicated she was a high-risk. Record review of a nursing progress note dated 10/07/25 at 12:15 PM by ADON G reflected Resident #1 had an unwitnessed fall in her room from a low bed and was discovered on the floor next to her bed. The progress note further reflected, Another resident alerted staff that resident was observed to be on the floor. Upon entering the room resident was next to bed already attempting to get back up and on knees next to w/c. Res unable to answer questions regarding intent. Res obs for injury, Neuro's (assesses the nervous system through a combination of tests on mental status, cranial nerves, motor and sensory function, coordination and balance, and reflexes) initiated, VS stable. Denies any c/o pain. Res assisted w/ 2 assist up to w/c No Pain. Interventions noted to be in place prior to fall were a floor mat and low bed. Interventions initiated in response to the fall were documented as, 1 on 1 supervision (involves a dedicated caregiver providing constant, undivided attention to prevent falls and ensure safety due to cognitive impairment). Record review of Resident #1's Transfer Notification nursing note dated 10/08/25 at 1:27 PM by ADON G reflected the resident had a fall at the nurses' station and hit her head. The fall caused an abrasion to the left side of the head. Resident #1 was noted to react to painful stimuli with any attempts to move her bilateral lower extremities and was bleeding. The nursing note further reflected, Resident was sitting in w/c at nurses' station when staff heard her scream. She was noted to be standing up and attempting to walk. She lost balance and hit her head against the nurses' station and landed on left side of body. No LOC noted and mentation (the overall mental activity of the mind, including thinking, memory, reasoning, perception, and consciousness) remained at baseline. VS assessed. Neuros assessed. Attempted to locate wounds/injury. EMS called. [RP] notified.Interventions in place prior to fall: 1 on 1 supervision. T Record review of Resident #1's care plan initiated 09/25/25 reflected a focus area/interventions for falls was initiated on 10/08/25 by the CCN and reflected, Focus: The resident is risk for falls (Date Initiated: 10/08/25)- Interventions/Tasks: 1) Anticipate and meet the resident's needs (Date Initiated: 10/08/25), 2) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Date Initiated: 10/08/25), 3) Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs (Date Initiated: 10/08/25), Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (Date Initiated: 10/08/25), Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (Date Initiated: 10/08/25), Keep furniture in locked position (Date Initiated: 10/08/25), Keep needed items, water, etc, in reach (Date Initiated: 10/08/25), Pt evaluate and treat as ordered or PRN (Date Initiated: 10/08/25), Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove [sic]any potential causes if possible. Educate resident/family/caregivers/IDT as to causes (Date Initiated: 10/08/25), Staff x 2 to assist with transfers (Date Initiated: 10/08/25), The resident needs a safe environment (Date Initiated: 10/08/25), The resident needs activities that minimize the potential for falls while providing diversion and distraction (Date Initiated: 10/08/25). An interview with CNA H on 10/15/25 at 1:02 PM revealed she worked with Resident #1 and assisted her with all ADLs including feeding, changing and transfers. CNA H stated Resident #1 could not stand or ambulate safely on her own and required hands-on help at all times. CNA H stated that staff had discussed Resident #1 needing a one-on-one person to be with her because she could not be left alone without risk of falling. She said the ADONs and charge nurses were aware Resident #1 needed constant monitoring and that she tried to keep the resident within sight while on duty, especially during meals and rounding the hall. CNA H stated Everyone knew she couldn't be left by herself. An interview with LVN D on 10/15/25 at 12:32 PM revealed she was aware Resident #1 was a high-risk for falls and that staff were expected to keep her within eyesight. She said she knew from change of shift report and staff discussion that Resident #1 required close monitoring and should not attempt to get up unassisted. An interview with LVN A on 10/15/25 at 3:55 PM revealed Resident #1 required increased supervision following her initial fall. She said she kept Resident #1 near the nurses' station in her wheelchair, So I could keep an eye on her. LVN A stated Resident #1 was confused and impulsive but pleasant, and she understood that nursing staff were expected to monitor her closely even though no one-on-one supervision was formally ordered. An interview with ADON G on 10/16/25 at 1:20 PM revealed she knew Resident #1 was a high fall risk and that increased supervision had been discussed after the first fall. She said she believed staff were keeping the resident near the nurses' station to maintain visual supervision but admitted she did not know whether she updated the care plan to reflect the need for 1:1 supervision. An interview with the ADO on 10/17/25 at 9:26 AM revealed when she reviewed the 10/07/25 fall incident report, it reflected 1:1 supervision had been selected as the intervention. She said ADON G entered the intervention but was unsure whether it had been communicated clearly to all shifts. The ADON said she assumed staff were aware of the supervision expectation but acknowledged that it may not have been documented in the care plan. An interview with ADON G was conducted on 10/18/25 at 12:26 PM and revealed the facility's policy when a resident fell was to update the care plan at the time of the incident and new interventions were expected to be documented by the end of the shift. ADON G stated the charge nurse was responsible for those updates with the assistance of MDS staff if available. ADON G said that waiting 24-hours to update the care plan was too long because documentation should reflect current risks and care being provided. She stated, If we are adjusting interventions, we need to record that. ADON G stated the charge nurse was responsible for initiating the care plan revision following a fall and that CNAs were notified of new interventions verbally before the plan was formally updated. A follow-up interview with the ADO on 10/18/25 at 12:43 PM revealed her expectation was that care plans were to be reviewed and updated during the same shift when an event or change in condition occurred. The ADO stated, During our daily morning stand-up, risk management is reviewed by the IDT team and interventions and updates are made at that time. The care plan revision-we can do them then. That's the gold standard. She clarified that charge nurses were responsible for initiating revisions and could place immediate interventions after a fall or change in condition. The ADO stated, If I am the DON, you're calling me after a resident falls, and I expect you to intervene and make it right. I try to communicate to my nurses to put a plan in place. She said new interventions post falls should be communicated to CNAs by updating the Kardex (a online documentation system, originally a brand name for a paper-based system, used primarily by nurses to keep a quick, organized summary of essential patient information) and through verbal handoff. She said the Kardex was the CNAs' quick look for what residents needed. Review of the facility's policy titled, Fall Policy (not dated) reflected, The Fall risk Assessment Tool will be completed at admission and after each fall occurrence. The assessment should be completed by reviewing the resident's medical history, social history and functional status. Information may be obtained by reviewing current medical records, interview with resident/family or conference with the interdisciplinary team members. The assessment tool should be scored and interventions implemented as indicated.Appropriate interventions will be addressed immediately on the interdisciplinary plan of care; reassessment will occur after each fall. Interventions will be resident centered. Record review of the facility's Comprehensive Care Plan Policy (not dated) reflected, Each person will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.Interventions are the specific care and services that will be implemented.The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS Assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of four residents (Resident #13) reviewed for catheter and incontinence care. 1. The facility failed to ensure NA E and CNA D maintained the foley catheter drainage bag below Resident #13's bladder during a mechanical lift transfer. 2. The facility failed to ensure CNA C did not place the urine catheter bag on the bed while performing incontinence care for Resident #13. These failures could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections. Findings included: 1. Record review of Resident #13's quarterly MDS assessment, dated 10/02/24, reflected a [AGE] year-old male with an admitted [DATE] and a re-admitted [DATE]. He had a BIMS of 9, which indicted he was moderately cognitively impaired. Resident #13 required substantial/maximum assist with ADLs and was dependent of 2 persons assist with transfers. He had an indwelling catheter and was always incontinent of bowel. Resident #13 had diagnoses which included obstructive uropathy (structural or functional hindrance of normal urine flow) and hemiplegia (paralysis that affects one side of the body). Record review of Resident #13's care plan, with a revision date of 08/29/24, reflected, The resident has 18 French (measurement of the circumference of the outer catheter tube) indwelling catheter related to obstructive uropathy .Goal .The resident will show no signs or symptoms of urinary infection through the review period .Interventions .Catheter anchor in place .Change as needed .Monitor/record/report to MD for signs and symptoms of urinary tract infection Record review of Resident #13's Order summary report, dated 11/13/24, reflected .Foley catheter care every shift and as needed . with a start date of 05/30/24. In an observation on 11/12/24 at 11:15 a.m. CNA C entered Resident #13's room to provide catheter care. CNA C washed hands and put on gloves. CNA C placed a towel on the floor and placed a plastic container on the floor and emptied the foley catheter drainage bag which contained approximately 150 cc of dark amber urine. CNA C emptied the container of urine, removed her gloves, and performed hand hygiene and put on clean gloves and proceeded to provide catheter care and incontinence care. CNA C unfastened the catheter drainage bag and placed in on the bed between the resident's feet. Urine was observed in the tube flowing back toward the resident. CNA C then unfastened the brief and pulled the foreskin back revealing moderate amount of white drainage around the penis head. CNA C cleaned in circular motion and then cleaned the catheter tubing from tip downward. ADON A entered Resident #13's room and performed hand hygiene and put on gloves. ADON A immediately picked up the catheter bag lying on the bed and placed it back on the bed frame ADON A and CNA C completed the incontinence care and removed their gloves and performed hand hygiene. In an interview with CNA C on 11/12/24 at 11:35 a.m. she stated the catheter bag was considered dirty and by placing it on the bed it was not below the bladder and urine could back up into the bladder. In an interview with ADON A on 11/12/24 at 11:40 a.m. he stated he walked into the room and observed the catheter bag on the bed and knew it was not supposed to be on the bed, and he instinctively stepped in and placed it in the proper place to ensure the flow of urine was not backing up toward the resident. He stated the staff were taught to always keep the urinary drainage bag below the bladder. In an observation with ADON A on 11/13/24 at 09:20 a.m. NA E and CNA D entered Resident #13's room with the Mechanical lift. Both staff washed their hands and put on gloves. Both staff maneuvered the lift around the resident's wheelchair and hooked the sling to the lift. NA E unhooked the catheter bag from the wheelchair and started to hook it to her pants legs when CNA D instructed her to hang it on the mechanical lift arm. NA E placed the catheter bag on the arm of the mechanical lift which was above the resident's bladder. The staff lifted the resident up with the catheter bag above the bladder and transferred him from the wheelchair to the bed. Staff then unhooked the urinary drainage bag and placed it on the bed frame. In an interview with ADON A on 11/13/24 at 09:30 a.m. he stated the urinary drainage bag was not supposed to be hooked to the mechanical lift during the transfer because it placed it above the bladder which could increase the risk of the urine backing up into the bladder and causing urinary tract infections. He stated he realized after the observations he had seen the past two days they needed to be observing the staff more frequently while they were providing care. He stated they had developed some bad habits and he needed to address how they were training and reinforce that training through more one-on-one observations during resident care. In an interview on 11/13/24 at 09:35 a.m. with CNA D she stated they were supposed to ensure the catheter tubing was over the resident's leg. She stated she was afraid if NA E had hooked the drainage bag to her pants it would pull the catheter too tight when they transferred Resident #13. She stated the catheter was supposed to be lower than the bladder but stated she really was not sure how they were supposed to keep it below the bladder during a mechanical lift transfer. She stated she guessed one of them should have held the catheter bag during the transfer. In an interview on 11/13/24 at 09:40 a.m. with NA E she stated they were supposed to always keep the catheter bag below the bladder to prevent the urine from flowing back toward the resident's bladder. She stated one of them should have held it below the bladder. In an interview with the DON on 11/13/24 at 01:00 p.m., he stated any resident with a foley catheter should always have the bag and tubing below the bladder and the bag should never be placed on the bed. He stated not keeping the foley catheter bag below the resident's bladder, placed them at risk of a urinary tract infection and cross contamination. He stated all the staff had been trained numerous times on the expectation. He stated to ensure staff were knowledgeable in the care of indwelling catheters and peri-care the facility did skills competency checks, but stated he and ADON A had discussed they were going to have to observe staff more frequently during resident care. Record Review of CNA D's skills check off dated 10/09/24 reflected she was competent in the care of indwelling catheters and infection control. Record Review of NA E's skills check off dated 10/08/24 reflected she was competent in the care of indwelling catheters and infection control. Record review of the facility's policy titled, Perineal Care, dated May 2024, did not address foley catheter care. Record review of the facility's undated skills assessment titled, Indwelling Catheter care, reflected, Ensure that the resident has a catheter secured in placed and a privacy bag for the urine collection bag. Never lift the catheter urine bag above the resident's bladder .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to ensure that two dented cans were removed and separated from the other canned food. 2. The facility failed to ensure that two cans of oven cleaner and two bottles of bleach were stored separately from food items in the dry storage room. 3. The facility failed to ensure the dry storage room floor was free from all items. 4. The facility failed to ensure hair restraints were worn properly during food preparation in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation of the dry storage room on 11/11/24 at 9:46 AM revealed two 6 lb. dented cans of apple slices mixed in with other canned foods. There were two cans of oven cleaner located on the shelf next to bottles of Worchester sauce and food coloring. There was also a box that contained two bottles of bleach and a box of cup lids that was located on the dry storage room floor. In a brief interview with Dietary Supervisor, with the Administrator present on 11/11/24 at 10:12 AM, she revealed that they had a dented' can sign next to the dented cans, but it must have fallen off. The Administrator left and returned with a dented can sign and taped it next to the dented cans located to the far right of the canned food shelf. Observation during lunch service on 11/11/24 at 11:45 AM revealed [NAME] L wore a hair restraint but had about 1/4 inch of hair out in the back and on the sides, while she scooped food onto resident's plates. Observation during lunch service on 11/11/24 at 11:45 AM revealed Dietary Aide M wore a hair restraint but had about 1/4 inch of hair out in the back and on the sides, while she plated residents' food trays. Dietary Aide N wore a hair restraint but had about 1/4 inch of hair out in the back, while she plated residents' food trays and Dietary Aide O wore a hair restraint but had exposed strands of hair, approximately six inches, on each side of her temples while she plated residents' food trays. In an interview with Dietary Aide M on 11/11/24 at 12:35 PM she revealed all hair is supposed to be covered underneath the hair restraint. She stated she was unaware any hair was out. She stated the risk to the residents was hair could fall into their drinks and food, which could cause them to choke. In an interview with [NAME] L on 11/11/24 at 12:41 PM she revealed all hair is supposed to be underneath the hairnet. She stated the risk to the residents was that the hair could fall into their food or drinks, which could cause them to choke. In an interview with Dietary Aide O on 11/11/24 at 12:43 PM she revealed hair was supposed to be fully covered underneath the hair restraint. She stated the risk to residents was hair could get into the resident's food and drinks, which could cause them to choke. In an interview with Dietary Aide N on 11/11/24 at 12:45 PM she revealed all hair is supposed to be underneath the hair restraint. She stated the risk to the residents was that hair could fall in their food and drinks, which could cause the residents to choke. In an interview with Dietary Supervisor on 11/11/24 at 12:47 PM she revealed she did not know there were dented cans mixed in with other canned food. She stated the dented cans should be stored with the other dented cans. She stated the cans of oven cleaner, and bottles of bleach should be stored in her office. She stated the cup lids should be stored on the shelf and not on the floor. She stated the risk to the residents due to these failures was contamination. She stated hair restraints are supposed to be worn over staff ears, covering all hair. She stated the risk to residents was that hair could get into the resident's food and drinks, which could cause them to choke. She stated her expectations of staff was to ensure that all hair was covered underneath the hair restraint. During an interview on 11/13/24 at 01:40 PM, the Administrator stated he expected hairnets to be worn to cover the entire head, dented cans placed in the dented can section, the floor should be free from all items and the oven cleaner, and bottles of bleach should be stored in their proper place. He stated these failures could potentially put residents at risk for cross contamination, and food borne illness. Record review of the facility policy titled 'Nutritious Lifestyle, Inc' dated 2012, revealed, All foods delivered are examined and foods that appear contaminated or have damage to the packaging are rejected, including any cans with swollen ends, leaks and flawed seals, rust and dents or containing no label. Dented cans or any item with damaged packaging is separated and kept in a separate designated area. Items are returned to the supplier on next delivery and a credit is requested. Record review of the facility policy titled 'Nutritious Lifestyle, Inc' dated 2012, revealed, Cleaning materials or other chemicals are not used or stored where they might contaminate foods. Chemicals are labeled and kept in their original containers when possible and stored in a locked area away from any food products. Record review of the facility policy titled 'Nutritious Lifestyle, Inc' dated 2012, revealed, Hairnets, headbands, caps, or other effective hair restraints shall be worn to keep hair from food and food-contact surfaces. Record review of the facility policy titled 'Nutritious Lifestyle, Inc' dated 2012, revealed, All items are stored at least 6 above the floor with adequate space between the items and the ceiling to allow for air flow and sprinkler system operation. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of 19 residents (Resident #77, Resident #15, Resident #13, and Resident #68) observed for infection control. 1. The facility failed to ensure LVN F used the required PPE for Resident #77, who was on enhanced barrier precautions due to her venous access device, while administering resident IV antibiotics on 11/11/24. 2. The facility failed to ensure that CNA B performed hand hygiene before moving to the clean supplies after completion of incontinence care to Resident #15 and before leaving the resident's room on 11/12/24. 3. The facility failed to ensure that CNA C and ADON A used the required PPE for Resident #13 who was on enhanced barrier precautions due to his foley catheter, while providing catheter and incontinence care on 11/12/24. 4. The facility failed to ensure CNA D and NA E used the required PPE for Resident #13, who was on enhanced barrier precautions due to his foley catheter, while performing a mechanical lift transfer on 11/13/24. 5. The facility failed to ensure CNA G performed hand hygiene while providing incontinence care to Resident #68 on 11/11/24. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Record review of Resident #77's Admission MDS assessment dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident had a BIMS score of 3 which indicated she was severely cognitively impaired. Diagnoses included type 2 diabetes mellitus and Osteomyelitis (infection in the bone). Record Review of Resident #77's Physician Orders Report on 11/11/24 reflected, Resident requires EBP Related to PICC line (a long, flexible tube that is inserted into a vein in the arm and used to deliver medications) until Discontinued every shift with a start date of 11/04/24. Record review of Resident #77's comprehensive care plan initiated on 10/23/24, reflected, Resident is on Enhanced Barrier Precautions related to PICC line .Interventions .Apply appropriate PPE during all High-Contact resident care activities . An observation of the medication pass on 11/11/24 at 10:55 a.m. revealed LVN F at the medication cart preparing Resident #77's intravenous antibiotic and gathering supplies needed for fingerstick blood sugar. LVN F entered Resident #77's room, performed hand hygiene and put on gloves, but did not put on a gown. LVN F cleaned the PICC line lumen (access line) with an alcohol wipe and flushed the PICC line with 10 cc of Normal Saline. LVN F then connected the IV line to the PICC line for the medication administration. LVN F then performed a fingerstick blood sugar on Resident #77 and obtained a reading of 113. LVN F returned to the medication cart and disposed of the lancet and test strip and removed his gloves and performed hand hygiene. He stated the IV would run about 30 minutes to an hour. A second observation on 11/11/24 at 12:15 p.m. revealed LVN F entering Resident #77's room to disconnect the IV infusion. LVN F performed hand hygiene and put on gloves, but no gown. LVN F disconnected the IV line from the resident's PICC line and flushed the PICC line with 10 cc of normal saline. LVN F removed his gloves and performed hand hygiene. In an interview with LVN F on 11/11/24 at 1:00 p.m. he stated Resident #77 was on Enhanced Barrier Precautions because of her IV access line. He stated he was supposed to wear a gown and gloves while providing care or medication administration to her PICC line and failed to do so. He stated he just forgot. He stated he had been in serviced on the use of Enhanced Barrier Precautions and what PPE was required. 2. Record review of Resident #15's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female with an admitted [DATE]. The resident had a BIMS of 15 which indicated she was cognitively intact. She required substantial to maximum assistance with toileting and transfers and was always incontinent of bladder and bowel. Diagnoses included hypertension (high blood pressure), diabetes, and a personal history of urinary tract infections. In an observation on 11/12/24 at 10:20 a.m. CNA B and ADON A entered Resident #15's room to provide a mechanical lift transfer and incontinence care. Both staff washed their hands and put on gloves and hooked the mechanical lift sling onto the lift and transferred the resident from her wheelchair to the bed. Both staff pulled the resident's pants down and unfastened the brief. CNA B wiped from front to back changing the wipes with each swipe. Without changing her gloves and performing hand hygiene, CNA B then reached into the plastic bag to retrieve the clean brief and laid it on the bed next to the resident. ADON A prompted her she needed to complete the peri care and both staff rolled the resident on her side revealing she had a small bowel movement. CNA B wiped from front to back and went to reach for the brief, when ADON A stopped her and told her to change her gloves. CNA B removed her gloves and then ADON A handed her a bottle of hand sanitizer and prompted her to sanitize her hands before putting on her gloves. CNA B sanitized her hands and put on gloves and then placed the brief on the resident and both staff pulled the resident's pants back up. Resident stated she wanted to get back up for lunch. CNA B removed her gloves and left the room without performing hand hygiene to retrieve the mechanical lift. CNA B returned to the room and washed her hands and put on gloves. ADON A removed his gloves and washed his hands and re-gloved. Both staff transferred the resident back to her wheelchair. ADON A positioned the resident and returned her overbed table in front of her, placed her call light within reach and went to the bathroom to wash his hands. CNA B gathered the dirty linens and trash and removed her gloves and left the room without performing hand hygiene. In an interview on 11/12/24 at 10:55 a.m. with the ADON A he stated the CNA B contaminated the clean brief when she reached into the bag and retrieved the brief before she had completed the peri-care. He stated he had to prompt her to change her gloves when she finished with the incontinence care before placing the clean brief on her. He stated the staff were to always perform glove changes and hand hygiene when going from dirty to clean. He stated they were to always wash their hands before leaving the resident's room if they had contact with the resident. He stated failing to do this placed resident at risk of infections and cross contamination. In an interview with CNA B on 11/12/24 at 11:00 a.m. she stated she thought she had performed hand hygiene when she left the room, but stated she may have forgotten. She stated she realized she had contaminated the brief and should have completed the care before moving to the clean brief. She stated she had received training on incontinent care but stated she was a new CNA and had trouble remembering some of the steps. 3. Record review of Resident #13's quarterly MDS assessment, dated 10/02/24, reflected a [AGE] year-old male with an admitted [DATE] and a re-admitted [DATE]. He had a BIMS of 9, which indicted he was moderately cognitively impaired. Resident #13 required substantial/maximum assist with ADLs and was dependent of 2 persons assist with transfers. He had an indwelling catheter and was always incontinent of bowel. Resident #13 had diagnoses which included obstructive uropathy (structural or functional hindrance of normal urine flow) and hemiplegia (paralysis that affects one side of the body). Record review of Resident #13's care plan, with a revision date of 08/19/24, reflected, The resident requires Enhance Barrier Precautions related to foley catheter .Interventions .Follow protocol for Enhanced Barrier Precautions . In an observation on 11/12/24 at 11:15 a.m. CNA C entered Resident #13's room to provide catheter care. CNA C washed hands and put on gloves but did not put on a gown. CNA C placed a towel on the floor and placed a plastic container on the floor and emptied the foley catheter drainage bag which contained approximately 150 cc of dark amber urine. Resident #13 was partially uncovered and observed resident had a loose stool that had leaked out of brief onto the sheets. CNA C emptied the container of urine, removed her gloves, and performed hand hygiene and put on clean gloves and proceeded to provide catheter care and incontinence care. CNA C unfastened the catheter drainage bag and placed in on the bed between the resident's feet. CNA C then unfastened the brief and pulled the foreskin back revealing moderate amount of white drainage around the penis head. CNA C cleaned in circular motion and then cleaned the catheter tubing from tip downward. CNA C then rolled the resident over and cleaned large soft bowel movement. ADON A entered Resident #13's room and performed hand hygiene and put on gloves but no gown. ADON A then removed the soiled linen and brief, changed his gloves, and performed hand hygiene and put on clean gloves. ADON A then applied barrier cream to the Resident buttocks. ADON A and CNA C completed the incontinence care and removed their gloves and performed hand hygiene. In an interview with CNA C on 11/12/24 at 11:35 a.m. she stated residents who had foley catheters were under enhanced barrier precautions and she was supposed to put a gown on when doing catheter care. She stated she just forgot to put on the gown. In an interview with ADON A on 11/12/24 at 11:40 a.m. he stated he should have put on gown before he started assisting with care for Resident #13. 4. In an observation with ADON A on 11/13/24 at 09:20 a.m. NA E and CNA D entered Resident #13's room with the Mechanical lift. Both staff washed their hands and put on gloves, but no gown. Both staff maneuvered the lift around the resident's wheelchair and hooked the sling to the lift. NA E unhooked the catheter bag from the wheelchair and started to hook it to her pants legs when CNA D instructed her to hang it on the mechanical lift arm. NA E placed the catheter bag on the arm of the mechanical lift. The staff lifted the resident up with the catheter bag and transferred him from the wheelchair to the bed. Staff then unhooked the urinary drainage bag and placed it on the bed frame. In an interview with ADON A on 11/13/24 at 09:30 a.m. he stated he realized after the observations he had seen the past two days they needed to be observing the staff more frequently while they were providing care. He stated they had developed some bad habits and he needed to address how they were training and reinforce that training through more one-on-one observations during resident care. He stated any resident with a foley catheter, or IV access line was always placed on enhanced barrier precaution. He stated he had in serviced the staff on the expectation. He stated he did not understand how they could not be following the protocol. In an interview on 11/13/24 at 09:35 a.m. with CNA D she stated they were supposed to put a gown for any care on Resident #15 because of the catheter. She stated she just forgot. In an interview on 11/13/24 at 09:40 a.m. with NA E she stated they were supposed wear a gown when doing care on Resident #13 because of the catheter. She stated they just did not think to put one on when they went in to put him in bed. She stated the risk was the spread of infection. In an interview with the DON on 11/13/24 at 01:00 p.m., he stated there had been a lot of confusion about the implementation of Enhanced Barrier Precautions on when it should be used. He stated they had in serviced the staff that for anyone with a catheter or PICC line they were required to wear a gown when performing direct care. He stated the risk was potential spread of multi-drug resistant organism from resident to resident. 5. Record review of Resident #68's quarterly MDS assessment dated [DATE] reflected she was an [AGE] year-old-female originally admitted to the facility on [DATE] and readmitted on [DATE]. Her BIMS score was 15 of 15 reflecting she was cognitively intact, required extensive, one-person assistance for ADLs and was always incontinent of bowel and bladder. Her active diagnoses included hypertension (elevated blood pressure), diabetes mellitus (elevated blood sugar), weakness, and morbid (severe) obesity due to excess calories. Observation on 11/11/24 at 11:05 a.m. revealed CNA G at Resident #68's bed side, wearing gown, and gloves. CNA G unfastened Resident#68's brief, and cleaned the resident's front area, using one wipe per stroke, front to back. CNA G helped Resident#68 turn to her left side revealing Resident had a bowel movement. CNA G cleaned the resident's buttocks area front to back using one wipe per stroke. CNA G removed the dirty brief, disposed of it in the trash can by the bed side, put a clean brief next to resident and then removed her gloves and put on clean gloves without performing hand hygiene. CNA G then applied barrier cream to the resident's buttocks area, put the brief under and turned the resident onto her back. She then applied barrier cream on Resident#68's front area. CNA G finished putting the brief on Resident#68 and fastened the brief. CNA G removed gloves, retrieved a disposable under pad and then put on clean gloves without performing hand hygiene, placed the under pad under the resident and adjusted the pillows under the resident's leg. CNA G covered Resident#68 and removed her gloves and gown and disposed of them in the trash bag. CNA G took the trash bag and disposed of it in a hamper in front of the room and returned to the resident's room and washed hands. In an Interview on 11/11/24 at 12:14 p.m. with CNA G she stated she knew she was supposed to perform hand hygiene between glove changes. CNA G stated she was supposed to have hand sanitizer with her, but stated she was gowned, and did not have one in the room. CNA G stated the risk to resident was cross contamination. She stated had been in serviced on hand hygiene a month ago. In an interview on 11/12/24 at 01:00 p.m. with DON he stated staff were supposed to wash hands and change gloves before, and after completion of cleaning a resident and after completion of care. He stated they had worked so hard with the staff on skills and stated they were all aware of what they were supposed to be doing. He stated the risk of failing to perform hand hygiene was increased infections and cross contamination. Record Review of LVN F's Nurse check off dated 10/08/24 reflected he was competent in infection control and the use of Personal Protective equipment. Record Review of CNA D's skills check off dated 10/09/24 reflected she was competent in the care of indwelling catheters, infection control and the use of Personal Protective equipment. Record Review of NA E's skills check off dated 10/08/24 reflected she was competent in the care of indwelling catheters, infection control and the use of Personal Protective equipment. Record Review of CNA B's skills check off dated 10/08/24 reflected she was competent in infection control and the use of Personal Protective equipment. Record Review of CNA C's skills check off dated 10/07/24 reflected she was competent in infection control and the use of Personal Protective equipment. Record Review of CNA G's skills check off dated 10/08/24 reflected she was competent in infection control and the use of Personal Protective equipment. Record review of the facility's policy, Enhanced Barrier Precautions, dated May 2024, reflected, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . Enhanced Barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .An order for enhanced barrier precautions will be obtained for residents with any of the following .urinary catheters .PICC lines .High contact resident care activities include Dressing, Bathing, Transferring, Providing hygiene, Changing linens, Device care or use: central lines, urinary catheters .PICC lines . Record review of the facility's policy titled, Hand Hygiene, dated June 2024, reflected, .2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . When, during resident care, moving from a contaminated body site to a clean body site .6. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . 47690

Based on observations, interviews, and record review the facility failed to ensure the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 5 residents (Resident #77) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system was within reach of the Resident #77, who was sitting in a wheelchair by the foot of the bed. This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers. Findings included: Record review of Resident #77's MDS assessment dated [DATE] reflected Resident #77 was an [AGE] year-old female with a BIMS score 03 of 15, indicating severe cognitive impairment. Resident #77 was admitted to the facility on [DATE] with the diagnoses of Diabetes Mellitus (elevated blood sugar), Dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and hypertension (elevated blood pressure). The review further reflected the resident was totally dependent on staff for the ADLs . Record review of Resident #77's Comprehensive Care Plan dated 11/11/24 reflected Focus. Resident#77 has impaired cognitive function/dementia or impaired thought process related to .impaired decision making. Goal. The Resident#77 Will be able to communicate basic needs on a daily basis through the review date. Interventions. Keep the Resident's routine consistent . in order to decrease confusion. Record review revealed no intervention of keeping the call light within reach of the resident. Observation on 11/13/24 at 08:43 AM revealed Resident#77 was sitting in her wheelchair by the foot of the bed, and the call light was lying by the head of the bed. Resident#77 stated she could not reach the call light. This state surveyor called LVN F inside the Resident#77's room and pointed to the call light by the head of the bed. LVN F stated the call light was not within reach of Resident#77. He took the call light and placed it closer to Resident#77 by the foot of the bed. Resident#77 took the call light and held it in her hand. Interview on 11/13/24 at 08:53 AM LVN F stated the call light was not within reach of the Resident#77. LVN F stated the call light should be within residents' reach all the time. LVN F stated the risk to the resident was not getting help he/she needed. LVN F stated it was the responsibility of all the staff to make sure the call light was within resident reach before exiting the room. Interview on 11/13/24 at 10:05 AM the DON stated his expectation was the call light should be always within resident reach. He stated it was the responsibility of all staff to make sure the call light is within resident reach. The DON stated the risk to residents, if the call light was not within resident reach or did not work properly, was the residents could not call for help. Review of the facility policy titled Call Lights: Accessibility and Timely Response, revised 05/01/2024 revealed The purpose of this policy is to assure the facility is adequately equipped with a call light to allow residents to call for assistance .5. Staff will ensure the call light is within reach of resident and secured, as needed.

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable environment, including but not limited to receiving treatments and supports for daily living for 1 of 5 residents (Resident #102) reviewed for quality of life. Facility staff/Hospice Aide failed to provide Resident #102 with clean linens. These failures could affect the residents by causing infections and skin issues. Findings include: A record review of Resident #102's MDS assessment dated [DATE] reflected Resident #102 was a [AGE] year-old male with a BIMS score of 00 of 15, indicating severe cognitive impairment. Resident #102 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, Dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), depression, and anxiety. The review further reflected the resident was on hospice services, and totally dependent on staff for the ADLs. A record review of Resident #102's Comprehensive Care Plan initiated date 10/01/24 reflected Problem. Resident#102 has a terminal prognosis related to senile degenerative of the brain. Utilized: Hospice services. Goal. Resident#102's comfort Will be maintained through the review date. Interventions .Keep the environment quiet and calm, keep linens clean, dry, and wrinkle free . Work with the nursing staff to provide maximum comfort for the resident. Observation on 11/13/24 at 07:55 AM of Resident #102 revealed that he was walking in the hall wearing daytime attire. Resident #102's linen (fitted sheet) was soiled with a feces smear at the middle of the bed, where Resident#102 would be if he was sitting at the edge of the bed. Resident#102 was unable to respond to interview. Observation and interview on 11/13/24 at 01:27 PM revealed Resident #102's bed still had the same soiled fitted sheet. The state surveyor showed the soiled linen to NA K, and NA K responded the fitted sheet was dirty. NA K stated she was assigned to the Resident#102, but the hospice aide was responsible for giving Resident#102 a shower and changing his bed linen. She further stated she did not notice the dirty linen and did not know when the last time Resident#102's bed linen was changed. NA K stated the risk to Resident#102 was development of infection. Observation and interview on 11/13/24 at 01:30 PM revealed LVN F entered Resident #102's room during the observation and interview with NA K. LVN F looked at Resident#102's bed linen fitted sheet, and stated it was dirty and need to be changed. LVN F stated the staff will change Resident#102's bed linen. LVN F stated the risk to Resident#102 was development of infection, and skin issues. Interview on 11/13/24 at 01:57 PM with Hospice Aide, she stated she was responsible for changing the linen on the days of the resident showers. The hospice Aide stated she gave a shower to Resident #102 this morning, and did not change the bed linen, because she could not find clean linen, and she looked in other Halls linen carts. The hospice Aide stated she could not recall the staff she notified. Interview on 11/13/24 at 02:05 PM with NA K and LVN F revealed, both denied been notified by the hospice Aide regarding Resident#102's bed linen not being changed after Resident#102's shower this morning. Interview on 11/13/24 at 02:19 PM with the DON revealed, he stated the hospice aides were responsible for giving residents in hospice services showers and changing the resident's linen on the shower day. DON stated not changing Resident#102's bed linen because the hospice aide could not find clean linen was not acceptable, and the hospice aide was supposed to communicate the issue with the management. The DON stated the hospice aides get training on residents' care via their agency. DON stated the risk to residents was infection, and skin issues. On 11/13/24 at 03:00 PM the facility administrator stated they do not have a policy for linen and safe clean comfortable home like. The facility did not submit a policy for linen and safe clean comfortable home like policy by the date and time of exit.

Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for one (Resident #8) of 5 residents reviewed for PASARR . The facility failed to refer Resident #8, who had an active diagnosis of Post Traumautic Stress Disorder (PTSD), to the appropriate state-designated authority for Level II PASARR evaluation. This failure could affect residents with mental disorders, intellectual disabilities, or a related condition by placing them at risk for not receiving needed treatment and services that could enhance their quality of life. Findings included: Review of Resident #8's quarterly MDS assessment dated [DATE] revealed an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses to include: hypertension (elevated blood pressure), diabetes Mellitus (elevated blood sugar), anxiety, depression, and PTSD. The resident had a BIMs score of 15, indicating her cognition was intact, and required substantial/maximal assistance with ADLs. There was not a diagnosis of dementia. Review of Resident #8's Medical Diagnosis Report dated 10/22/19 revealed, Post Traumatic stress disorder. Review of Resident #8's PASARR Level 1 screen dated 09/06/19 revealed Effective date: 09/06/2019, Resident#8. MI/ID/DD : N-N-N. admitted : yes. Status date: 09/06/2019. Status: Negative PASRR (sic) Eligibility. Review of Resident#8's psychological evaluation dated 01/30/22 revealed Resident#8 was referred for psychological service in April of 2017 due to anxiety and picking at her skin, at which time she was diagnosed with adjustment disorder and PTSD. currently carries the diagnoses of F43.10 post-traumatic stress disorder . Interview on 11/13/24 at 07:58 AM. with the Administrator revealed, he stated the Social Worker and the MDS coordinator were responsible for resident record review during the resident admission and with any changes in the resident status thereafter. Interview on 11/13/24 at 08:24 AM with Social Worker revealed, she stated she was not responsible for completing the PASARR level 1. She stated the MDS coordinator was responsible for completing the PASARR level 1 and following with the residents. She stated her responsibility on admission was to do the resident code status and schedule the care plan meeting. Interview on 11/13/24 at 09:34 AM with the MDS coordinator revealed she was responsible for the PASARR level 1. The MDS coordinator stated when a resident admits to the facility, she reviewed the resident's information documenting the admission information on the PASARR level 1. She stated if the resident had a diagnosis of Mental Illness Health, she would answer yes to the question asking if they had a diagnosis. MDS coordinator stated the LA would come to complete a PASARR level 2 to see if the resident qualifies for services. She stated Resident#8 had been living in the facility since 2016, and the PASARR level 1 done for Resident#8 on 09/06/19 was related to the facility change of ownership. She stated that the follow-up for the PASARR 1 was her responsibly, and the SW would notify her if she noticed some change in the resident diagnosis, and the MDS coordinator would report to the LA. The MDS coordinator gave examples of diagnosis that she would check yes for: Schizophrenia, bipolar disorder, psychosis, anxiety with psychosis. The MDS coordinator stated it could had been missed, because she did not know that PTSD was a diagnosis that will qualify the residents for PASARR level 2 evaluation. She stated that the follow-up for the PASARR 1 was her responsibly and the meetings were also her responsibility, if the residents qualified for services (specialized services) it would be the responsibility of the department manager to receive the orders and initiate the services. Interview on 11/13/24 at 09:50 AM with Resident #8 revealed she did not know anything about PASARR or specialized services, no one had talked to her about that. The resident said if she was entitled to something, she wanted to be able to get it. Interview on 11/13/24 at 10:05 AM with the DON revealed, he stated the MDS coordinator took care of the PASARR reports. The DON stated he did know that PTSD was a qualifying diagnosis for PASRR. The DON stated if the assessment was not completed properly, he thought the resident might not get services she needed. Record review, no date, of facility's form, Active Residents with PASARR Positive PI , did not include Resident #8. Review of the facility's policy and procedure Resident Assessment-Coordination with PASRR (sic) program implemented March 01, 2023, reflected, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review .a. A resident who exhibits behavioral, psychiatric, . symptoms . (where dementia is not the primary diagnosis).

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one of seven (Residents #77) residents reviewed for pharmacy services. The facility failed to ensure LVN F followed the procedure for accurate administration of Resident #77's Insulin Glargine Solution 15 unit when he held the daily dose of Insulin without notifying the physician on 11/11/24. These failures placed residents at risk of not receiving a therapeutic dosage of medication. Findings included: Record review of Resident #77's Admission MDS assessment dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident had a BIMS score of 3 which indicated she was severely cognitively impaired. Diagnoses included type 2 diabetes mellitus and Osteomyelitis (infection in the bone). Record Review of Resident #77's Physician Orders Report on 11/11/24 reflected, Insulin Glargine Solution 100 unit/ml (long-acting insulin that increases insulin levels in the body to help decrease blood sugar) inject 15 unit subcutaneously one time a day for diabetes related to type 2 diabetes mellitus without complications until 11/15/24 with a start date of 11/07/24. There were no parameters for when to hold the insulin. An observation of the medication pass on 11/11/24 at 10:55 a.m. revealed LVN F performed a fingerstick blood sugar on Resident #77 and obtained a reading of 113. LVN F returned to the medication cart and disposed of the lancet and test strip and placed the glucometer on top of the medication cart and stated he was holding Resident #77's Glargine Insulin because he did not want her blood sugar to bottom out. LVN F documented into the electronic medication administration record the resident's blood sugar level and documented the medication was held. In an interview with LVN F on 11/11/24 at 1:00 p.m. he stated he held Resident #77's insulin but did not notify the doctor. He stated there were no parameters for when to hold her insulin for the routine insulin, but there were parameters for the sliding scale. He stated he should have notified the physician. In an interview on 11/12/24 at 01:00 p.m. with the DON he stated anytime a medication was held that did not have specific parameters they should notify the physician. He stated holding a medication could result in the resident not receiving the therapeutic dose of medication which could worsen the resident's conditions. He stated they had followed up with the physician on 11/11/24 after becoming aware the insulin was held and they now had parameters in place for when to hold Resident #77's maintenance dose of insulin. In an interview on 11/13/24 at 10:15 a.m. with the facility's Pharmacy consultant, she stated missing a dose of maintenance insulin could result in not having a constant therapeutic level in the resident's system when it was every 24 hour medication. She stated they usually do not have parameters on holding maintenance insulin, but if it was held, they would need to notify the physician for orders. Record Review of Resident #77's Physician Orders Report dated 11/12/24 reflected, Insulin Glargine Solution 100 unit/ml inject 15 unit subcutaneously one time a day for diabetes related to type 2 diabetes mellitus without complications until 11/15/24 Hold for blood glucose less than 140 . with a start date of 11/11/24. Record review of LNV F's Nurse check off list dated 10/08/24 reflected he was competent in Medication administration. Record review of the facility's policy, Medication Administration, dated May 2024, reflected, Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice When applicable, hold medication for those vital signs outside the physician's prescribed parameters .Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects .Administer medication as ordered in accordance with manufacturer specifications Record review of the facility's policy, Timely Administration Insulin, dated May 2024, reflected, It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition .All insulin will be administered in accordance with physician's orders .

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 3 of 4 halls (Hall 100, Hall 200, Hall 300), 1 of 1 nurses' station. The facility failed to ensure Hall 100, Hall 200, Hall 300, and nurses' station were free from gnats. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life. Findings included: Observation of Hall 100 on 09/17/23 11:16 AM, Hall 100 revealed gnats circling in Resident #61's room and landing on his bedside table with personal items. Observation and interview of Hall 200 on 09/17/23 beginning at 11:58 AM, with Resident #3 and Resident #72 revealed gnats flying around room, Resident #3 had a fly swatter in her hand. Resident #3 stated her family member had purchased both her and Resident #72 fly swatters to kill gnats flying in their room. Resident #72 had gnats landed on her bedside table, landed on the privacy curtain, flying around her side of the bed, and over personal items. Observation of Hall 200 on 09/18/23 at 9:08 AM, Resident #75 had at least 5 gnats flying around resident room, fly swatter was observed at nightstand table. Observation of Hall 200 on 09/18/23 at 9:32 AM, Resident #78 had at least 8 gnats landed on her privacy curtain and flying over her bed. During the confidential resident group interview on 09/18/23 at 9:48 AM, 9 of the 13 residents in attendance revealed the facility had an issue with gnats. Residents stated they have observed pest control treat the facility but does not seem to work. Residents stated at this point they are just used to them. Observation on 09/19/23 11:35 AM, there were a few gnats flying around the nursing station while surveyor was interviewing staff. During interview on 09/19/23 at 10:27 AM, LVN C revealed the facility did have a big issue with flies, the facility had gotten rid of the flies and for a few weeks we were ok. LVN C stated a couple of days ago she began to see gnats starting to appear. LVN C stated she has seen pest control in the facility, and she has seen the Maintenance Director spraying to get rid of the gnats. According to LVN C when she saw gnats, she would inform the Maintenance Director. LVN C stated having gnats in the facility could cause infection and cross-contamination causing residents to possibly become ill. During interview on 09/19/23 at 3:17 PM, Housekeeper J revealed she had noticed gnats in the facility this past weekend while working on the 300 Hall. Housekeeper J stated she noticed most gnats in rooms beside the shower room. Housekeeper J stated she has observed the Maintenance Director going in and spraying for the gnats. Housekeeper J stated she also will use her disinfectant spray in an attempt to kill gnats. Housekeeper J stated she had not received complaints from residents about the gnats, however received complaints from nursing staff that there was a lot of gnats in the building. Housekeeper J stated it was her responsibility to report the gnats to the Maintenance Director so that he could treat them or call pest control. Housekeeper J stated she would usually write down in the maintenance log when she needs the Maintenance Director to address pest and she notified her supervisor. During interview on 09/19/23 at 3:32 PM, the DON revealed the facility had a company that came out a couple of months ago. The pest control company put something in different areas of the facility that got rid of pest like gnats. The DON stated they had placed fly bags out front, gnat lights, and an air curtain for the kitchen. The DON stated he noticed gnats last Friday. According to the DON having gnats flying around the facility could cause illness and cross contamination. The DON stated the Maintenance Director was responsible for contacting pest control to remove the gnats. During interview on 09/19/23 at 3:50 PM, the Maintenance Director revealed the facility has had an issue with gnats and flies. Maintenance Director stated pest control has come out to spray to get rid of the gnats. The Maintenance Director stated the facility installed gnat fly lights, in July, completed power washes at each entrance and hung fly bags. The Maintenance Director stated with the weather being so bad and the doors swinging open, gnats were able to enter the facility. The Maintenance Director stated he was responsible for contacting pest control to come out and spray if he saw gnats in the building or facility staff would alert him of a problem. The Maintenance Director stated having gnats in the building was unsanitary. Record review of facility pest control binder revealed the following: 8/28/23 resident room in restroom, 8/29/23 100 hall gnats, 9/06/23 resident room gnats kit, 9/18/23 resident room gnats kit, 9/19/23 300 hall gnats. Record review of facility's Pest Control policy, revised May 2008, reflected: Our facility shall maintain an effective pest control program. .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. .Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on interview and record review, the facility failed to ensure residents were treated with dignity and respect for 2 of 3 residents (Residents #2 and #67) reviewed for resident rights. The facility failed to ensure Hospitality Aide A treated Residents #2 and #67 with respect and dignity in her interactions with them in April 2023. This failure led to the residents having feelings of decreased self-worth. Findings included: Review of Resident #2's Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia falls, anxiety, and depression. Review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 5 indicating severe cognitive impairment. Her Functions Status revealed she required extensive assistance with most of her ADLs. Review of Resident #2's care plan, dated 09/07/23, revealed she required the assistance of staff for her ADLs, with interventions of providing a mechanical lift for transfers. Review of Resident #67's Admission Record revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment, diabetes, non-pressure related chronic ulcer, and muscle weakness Review of Resident #67's quarterly MDS, dated [DATE], revealed a BIMS score of 14, indicating intact cognition. Her Functional Status indicated she required extensive assistance with most of her ADLs. Review of Resident #67's care plan, dated 08/03/23, revealed she required the use of a mechanical lift to transfer, and an electric wheelchair to move about, with intervention of physical help for the resident. Interview on 09/17/23 at 11:29 AM, Resident #2 stated she had an incident in April 2023 that she reported to the nurse and the Administrator. Hospitality Aide A was putting her back to bed, using the Hoyer Lift, when she struck Resident #2's leg against the TV stand. Resident #2 stated when she told the aide that it hurt, the aide was very rude and cursed at her. Resident #2 stated it was not the first time this had happened, but this time there was a witness to confirm it. Resident #2 stated the situation made her feel bad about herself because she knew she was fat and did not need to be reminded of it. Interview on 09/17/23 at 11:40 AM, Resident #67 stated the Social Worker had come around asking if any staff had been abusive towards her, and she reported that in April of 2023 Hospitality Aide A had caught her foot under the bed while using the Hoyer lift to transfer her. When Resident #67 told Hospitality Aide A her foot was stuck under the bed, Hospitality Aide A just pulled the Hoyer lift back, scraping the top of Resident #67's foot on the underside of the bed. When Resident #67 mentioned that it hurt, Hospitality Aide A just continued about her business as if nothing had happened and never apologized for it. Resident #67 stated she felt frustrated and upset afterwards that the aide just acted like nothing had happened. Interview on 09/19/23 at 10:28 AM, the DON stated he had been made aware of the accusation of Hospitality Aide A being verbally abusive towards Resident #2 on 04/18/23 and began his investigation. Based on his interviews with Hospitality Aide B, Resident #2, and the results of the Safety Surveys, Hospitality Aide A was terminated in April 2023. Interview on 09/19/23 at 11:20 AM, Hospitality Aide B stated she had been working with Hospitality Aide A in April of 2023 when they entered Resident #2's room to put her back to bed. Hospitality Aide A had lifted Resident #2 out of her wheelchair and in the process of moving her to the bed she accidentally hit the resident's foot on the furniture. When Resident #2 said something about it hurting Hospitality Aide A stated, If you don't quit fucking bitching so much, I'm going to just leave your fat ass in the bed all day. Hospitality Aide B stated she knew this was wrong and reported it to the nurse as soon as she could. Phone interview on 09/19/23 at 3:26 PM, Hospitality Aide A stated she had no recall of the event in April 2023, and she terminated the interview. Review of the facility's Prohibiting and Preventing Abuse, Neglect, Exploitation, and Misappropriation of Property policy and procedure, dated 2022, described verbal abuse as: .including but not limited to the use of oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents .Examples include cursing, yelling, name calling, threatening or saying things to frighten a resident .

Based on interview and record review, it was determined the facility failed to develop a comprehensive care plan, which included measurable objectives and timetables to meet a resident's medical and nursing needs that are identified in the comprehensive assessment for one (Resident #11 ) of 16 residents reviewed for comprehensive care plans. Resident #11 was admitted to the facility on [DATE] with a reddened area on her sacrum. Upon admission, the facility identified Resident #11 as being at risk for pressure ulcers. On 05/07/14, the resident developed a Stage III pressure ulcer with slough on her sacrum one day after still being assessed as having a reddened area. There was no comprehensive care plans addressing the resident's risk for developing pressure ulcers, [DIAGNOSES REDACTED]. These failures resulted in Resident #11 developing a Stage III pressure ulcer with slough, and placed the one resident, who was bed-bound, the four residents with pressure ulcers and the 45 residents receiving preventive skin care at risk for not having interventions identified to prevent the development of pressure ulcers or resulting in a decline in current pressure ulcers. Findings included: Resident #11 was a [AGE] year-old female who was admitted to the facility on [DATE], for rehabilitation post-fall with multiple fractures of the left arm. The most recent MDS assessment, dated 04/29/14, reflected Resident #11 had [DIAGNOSES REDACTED]. Her BIMS reflected a score of "14," indicating Resident #11's cognition was intact. Further review of the assessment reflected Resident #11's functional status as follows: "bed mobility - extensive assistance, two-person physical assist. Transfer - extensive assistance, one-person physical assist. Dressing - extensive assistance, toileting - extensive assistance two person physical assist. Balance surface to surface - not steady only able to stabilize with staff assistance. ROM upper extremity impairment on one side. Urinary continence - frequently incontinent, bowel continence - occasionally incontinent. Skin conditions; Is resident at risk of developing pressure ulcer - NO. Resident has Stage 1 or higher pressure ulcers - NO." In addition, the MDS reflected the CAA Summary "checked" the following skin related categories: "pressure ulcer triggered, pressure ulcer plan, location and date of CAA information - skin assessment, potential." During initial rounds on 05/13/14 at approximately 10:50 AM accompanied by LVN D, Resident #11 was observed sleeping in bed on an air mattress with foam bumpers. She had multiple pillows to assist with positioning and had pillows under her left arm which was in a brace. LVN D stated that Resident #11 was a new admission residing at the facility for the past three to four weeks for rehab post-fall at home and she fractured her left arm. The resident was diabetic and had vision impairment. She was expected to return home after her rehabilitation was completed. LVN D revealed that Resident #11 had a Stage III pressure ulcer to her coccyx/sacrum area that recently developed. Resident #11 needed assistance with most ADLs and had experienced pain due to her fractured arm and pressure ulcer. Resident #11 was continent of both bladder and bowel. Resident #11 had a history of [REDACTED]. Interview with LVN D on 05/14/14 at 12:05 PM, revealed that Resident #11 had redness noted to her buttocks upon admission and up until the area opened. LVN D stated that the zinc oxide barrier cream was ordered and applied to the resident every day as a preventive. She revealed she did not know the area had opened up until it was reported to her on 05/07/14, and at that time the wound doctor saw the resident and they obtained orders for wound care that day. When queried about the assessment of the pressure ulcer on 05/06/14, LVN D stated she could not see the pressure ulcer very well when she looked at it. LVN D stated she was responsible for skin assessments on the hallway in which Resident #11 resided. When an area was noted to be opened, it would be reported to ADON A who was responsible for wound care plans and obtaining orders. Interview with LVN D on 05/15/14 at 9:00 AM, revealed the pressure ulcer for Resident #11 was staged as a Stage III due to the "slough" present on the wound. She stated the resident had the reddened area since admission and would occasionally state her "bottom" was sore. LVN D stated the nursing interventions used to prevent pressure ulcers included, application of the zinc oxide barrier cream, and positioning which was done by the CNAs. LVN D could not remember when Resident #11 received the low-loss air mattress or the wheelchair cushion, but was able to find the order for those items after reviewing the physician's orders [REDACTED]. Observation of the wound on 05/15/14 at 9:40 AM, accompanied by LVN D and ADON A revealed a small, dime-sized, opened area to the sacrum. The area was covered with yellow-white colored slough, which could not be removed by cleansing the area. There was scar tissue and discoloration along both sides of the crease of the buttocks indicating the skin had previous breakdown. LVN D stated the wounds were measured weekly by the wound doctor and all the paperwork and care plans for wounds were completed by ADON A who accompanied the doctor on rounds. Interview with ADON A on 05/15/14 at 10:00 AM, revealed that when a resident was admitted with any history of skin breakdown or redness noted, zinc oxide would be ordered and the treatment would begin as a preventative. ADON A stated she first learned of Resident #11's pressure ulcer the prior week when it was reported to her. She stated when a wound was identified, she was responsible to write the care plan. She stated she did not usually write a care plan for "the potential for skin breakdown," and revealed she was only involved in the care of the wound once it opened up. ADON A stated the admitting nurse would write any care plan to identify the residents needs until the MDS assessment was completed. ADON A stated that air mattresses and wheelchair cushions were ordered for Stage II (or higher) pressure ulcers. ADON A stated the care plan for the wounds were kept on the treatment cart. Interview with the DON on 05/15/14 at 3:45 PM, revealed that Resident #11 admitted to the facility with redness to her "backside" and had pain associated with mostly her arm. The DON stated the resident was not very mobile after admission and spent most of her time in bed. The DON revealed that the resident was not care-planned until the wound developed, as they "usually don't care plan skin." The DON stated the resident was at risk for developing pressure ulcers due to her inactivity, diabetes, and history of wounds. She stated the resident was care-planned after the wound presented and they did not have preventative measures or care plans other than applying the barrier cream and frequent repositioning. The DON stated that the air mattress and wheelchair cushions were only implemented when a resident had a Stage II or greater pressure ulcer. The DON stated the MDS nurse was responsible for writing care plans and the ADON wrote care plans specific to wounds. She stated she would begin working on an admission assessment tool regarding skin and the potential for breakdown. The DON agreed that Resident #11 was a high risk for skin breakdown and had a risk of developing pressure ulcers. Interview with LVN F on 05/15/14 at 4:45 PM, revealed she was the nurse who admitted Resident #11 to the facility. She stated she saw the reddened area on her sacrum and noted it on the assessments paperwork. LVN F stated she wrote the order for the barrier cream and started the initial care plan. LVN F stated that Resident #11 was mostly in bed if she was not in therapy due to the pain. Resident #11 would complain about pain in her arm mostly, and would also complain that her "bottom was sore." LVN F revealed that residents did not get air mattresses or wheelchair cushions until an area on the skin had opened. Review of the facility's "Weekly Skin Integrity Review" sheets reflected the following skin assessments: 04/22/14 - admission skin condition - redness to the sacrum was identified/noted on the diagram of the body. 04/30/14 - redness to the perineal area and buttocks. 05/06/14 - skin assessment redness to the buttocks. 05/13/14 - Stage III to the sacrum area. Review of Physician's Telephone Orders, revealed on 04/22/14, Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. Cleanse wound to sacrum with normal saline, pat dry, apply Hydrogel gauze and cover with foam dressing daily and as needed... 2. Low air loss mattress when available. 3. Wheel chair cushion to chair. 4. Multivitamins with minerals, one tablet daily. 5. Stress tablet with zinc PO BID for 10 days. 6. Vitamin A 8000 IU, one tab PO for 10 days. 7. [MEDICATION NAME], mix one packet with 8 oz. fluid of choice BID for 14 days." Review of the "Daily Skilled Nurse's Note," revealed Resident #11 was admitted with redness noted to buttocks on 04/22/14. The nurses' note reflected that barrier cream was applied. Further review of nurses' notes reflected the redness continued to be present on Resident #11's buttocks/sacrum area through 05/06/14. Review of the facility's "Braden Scale for Predicting Pressure Sore Risk" assessment tool, dated 04/22/14, revealed Resident #11 scored a "17," indicating the resident was "at risk" of developing pressure ulcers. Review of Resident #11's complete "Care Plans," dated 05/02/14, revealed no complete comprehensive care plans identifying the resident was at risk for skin breakdown, or at risk for developing pressure ulcers. Resident #11 had the following care plans with the start date of 05/02/14. "At risk for deterioration of vision due to Diabetes and [MEDICAL CONDITION] is on Diuretic Medication...Hypertension - requires daily medication and monitoring...Resident has been identified as a risk for falls...Potential for pain...Resident at risk for allergic reaction related to allergies [REDACTED]." Review of the facility's "Short Term Care Plan" for Resident #11, dated 05/07/14, identified the following problem: "Patient with Impaired Skin Integrity - Pressure Ulcer Stage 3 - location -sacrum. Goal: Patient will improve skin integrity over the next four weeks. Interventions: Preventative mattress, wheel chair cushion in chair, multivitamin with minerals, stress tabs with zinc twice a day for 10 days, Vitamin A 8,000 IU by mouth for 10 days, Increase protein daily with [MEDICATION NAME], If incontinent barrier cream after each incident, weekly skin assessment, measure and evaluate weekly, apply treatment/dressing as ordered...." Review of the facility's undated policy and procedure for "Routine Skin Care," revealed the following: "Use appropriate pressure relieving devices for bed and chair, turn and position at least every two hours in bed and relieve position when in chair...off load/pad bony prominences as necessary, provide incontinent care as needed, all stage three and four pressure ulcers will be placed on a specialty mattress." The facility's Resident Census and Conditions of Residents Form CMS-672 completed and signed by MDS Coordinator J on 05/13/14 reflected one resident was bed-bound, four residents had pressure ulcers and 45 residents were receiving preventive skin care.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary treatment and services to promote healing for one (Resident #11) of five residents reviewed for pressure ulcers and failed to provide one (Resident #4) of five residents reviewed for pressure ulcers, who was at risk for developing pressure ulcers, assistance with timely repositioning. 1) Resident #11 was admitted to the facility on [DATE] with a reddened area on her sacrum. Upon admission, the facility identified Resident #11 as being at risk for pressure ulcers. On 05/07/14, the resident developed a Stage III pressure ulcer with slough on her sacrum one day after still being assessed as having a reddened area. 2) The facility failed to turn and reposition Resident #4, who had a history of [REDACTED]. These failures could affect the facility's single resident who was bedfast, the four residents with pressure ulcers and the 45 residents receiving preventive skin care, plus Residents #4 and #11, and placed them at risk for developing pressure ulcers and/or worsening of current pressure ulcers. Findings included: 1) During initial rounds on 05/13/14 at approximately 10:50 AM and accompanied by LVN D, Resident #11 was observed sleeping in bed on an air mattress with foam bumpers. She had multiple pillows to assist with positioning and had pillows under her left arm, which was in a brace. LVN D stated Resident #11 was a new admission residing at the facility for the past three to four weeks for rehab, post-fall at home and she fractured her left arm. The resident was diabetic and had vision impairment. She was expected to return home after her rehabilitation was completed. LVN D further stated Resident #11 had a Stage III pressure ulcer on her coccyx/sacrum area, which had recently developed. Resident #11 needed assistance with most ADLs and had experienced pain due to her fractured arm and pressure ulcer. Resident #11 was continent of both bladder and bowel. Resident #11's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old female, was admitted to the facility on [DATE], for rehabilitation post-fall with multiple fractures of the left arm. The most MDS assessment, dated 04/29/14, reflected [DIAGNOSES REDACTED]. Her BIMS reflected a score of "14," indicating Resident #11's cognition was intact. Further review of the MDS assessment reflected Resident #11's functional status as follows: Bed mobility - extensive assistance, two-person physical assist. Transfer - extensive assistance, one-person physical assist. Dressing - extensive assistance, toileting - extensive assistance two person physical assist. Balance surface to surface - not steady only able to stabilize with staff assistance. ROM (range of motion) upper extremity impairment on one side. Urinary continence - frequently incontinent, bowel continence - occasionally incontinent. Skin conditions; and "Is resident at risk of developing pressure ulcer - NO." "Resident has Stage 1 or higher pressure ulcers - NO." In addition, the MDS assessment reflected the CAA Summary checked the following skin related categories: pressure ulcer triggered, pressure ulcer plan, location and date of CAA information - skin assessment, potential. Review of the facility's Braden Scale for Predicting Pressure Sore Risk assessment tool, dated 04/22/14, reflected Resident #11 scored a "17," indicating the resident was "at risk" for developing pressure ulcers. Review of Physician's Telephone Orders reflected on 04/22/14, Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. In addition, on 04/22/14, an order for [REDACTED]. Review of the facility's Weekly Skin Integrity Review sheets reflected the following skin assessments for Resident #11: --04/22/14 admission skin condition - redness to the sacrum was identified/noted on the diagram of the body. --04/30/14 redness to the perineal area and buttocks. --05/06/14 skin assessment redness to the buttocks. --05/13/14 Stage III to the sacrum area. Review of Resident #11's complete Care Plans, dated 05/02/14, revealed no complete comprehensive care plans identifying the resident as being at risk for skin breakdown, or at risk for developing pressure ulcers. Resident #11 had the following care plans: At risk for deterioration of vision due to Diabetes and [MEDICAL CONDITION] is on Diuretic Medication...Hypertension - requires daily medication and monitoring...Resident has been identified as a risk for falls...Potential for pain...Resident at risk for allergic reaction related to allergies [REDACTED]." Review of the Daily Skilled Nurse's Note reflected Resident #11 was admitted with redness noted to buttocks on 04/22/14. The nurses' note reflected barrier cream was applied. Further review of Nurses' notes reflected the redness continued to be present on Resident #11's buttocks/sacrum area through 05/06/14. Review of the Nurse's Notes for 05/07/14, revealed the following: "8:00 AM - New order for (Physician) to see and treat as indicated for wound to sacrum...3:00 PM - Res (Resident) seen by (Physician) for wound rounds. Stage 3 wound present to sacrum measuring at 2.5 x 1.0 x 0.2 cm. Covered with 40% yellow slough. Some debridement done today. No complaints of pain, tolerated treatment well. New order - 1. Cleanse wound to sacrum with normal saline, pat dry, apply Hydrogel gauze and cover with foam dressing daily and as needed...2. Low air loss mattress when available. 3. Wheel chair cushion to chair. 4. Multivitamins with minerals, one tablet daily. 5. Stress tablet with zinc PO BID for 10 days. 6. Vitamin A 8000 IU, one tab PO for 10 days. 7. [MEDICATION NAME], mix one packet with 8 oz. fluid of choice BID for 14 days." On 05/07/14, when the Stage III pressure ulcer was discovered, the following physician orders [REDACTED]. Cleanse pressure ulcer to sacrum with normal saline, pat dry, apply Hydrogel gauze and cover with foam dressing daily and as needed...2. Low air loss mattress when available. 3. Wheel chair cushion to chair. 4. Multivitamins with minerals, one tablet daily. 5. Stress tablet with zinc PO BID for 10 days. 6. Vitamin A 8000 IU, one tab PO for 10 days. 7. [MEDICATION NAME], mix one packet with 8 oz fluid of choice BID for 14 days. Interview with LVN D on 05/14/14 at 12:05 PM, revealed Resident #11 had redness noted to her buttocks upon admission and up until the area opened. LVN D stated the zinc oxide barrier cream was ordered and applied to the resident every day as a preventive. She stated she did not know the area had opened up until it was reported to her on 05/07/14, and at that time, the wound doctor saw the resident and they obtained orders for wound care that day. When queried about the assessment of the pressure ulcer on 05/06/14, LVN D stated she could not see the pressure ulcer very well when she looked at it. LVN D stated she was responsible for skin assessments on the hallway in which Resident #11 resided. When an area was noted to be opened, it would be reported to ADON A, who was responsible for wound care plans and obtaining orders. Interview with LVN D on 05/15/14 at 9:00 AM revealed the pressure ulcer for Resident #11 was staged as a III due to the presence of "slough (soft, dead tissue)." She stated the resident had the reddened area since admission and would occasionally state her bottom was sore. LVN D stated the nursing interventions used to prevent pressure ulcers included application of the zinc oxide barrier cream and positioning, which was done by the CNAs. LVN D could not remember when Resident #11 received the low-loss air mattress or the wheel chair cushion. She was able to find the order for those items after reviewing the physician's orders [REDACTED]. Observation of the pressure ulcer on 05/15/14 at 9:40 AM, accompanied by LVN D and ADON A, revealed a small, dime-sized, opened area on the sacrum. The area was covered with yellow-white colored slough, which could not be removed by cleansing the area. There was scar tissue and discoloration along both sides of the crease of the buttocks indicating the skin had previous breakdown. LVN D stated the pressure ulcers were measured weekly by the wound doctor and all the paperwork and care plans for wounds/pressure ulcers were completed by ADON A, who accompanied the doctor on rounds. RN C was interviewed on 05/15/14 at 8:50 AM. RN C stated if a resident's skin was noted to be red, the intervention would be to apply a skin barrier to the area. She stated the skin should be kept dry and clean. In regard to Resident #11, RN C stated the resident spent time in her wheelchair, but had spent most of her time in bed. She stated Resident #11 could not turn to her left side due to the fractured arm and the brace on her arm. She said the resident was mostly on her "backside." RN C stated the area was "reddened for some time," and the resident would state "it did not feel right." RN C could not remember when the air mattress and wheelchair cushion were initiated for Resident #11. Interview with ADON A on 05/15/14 at 10:00 AM, revealed when a resident with any history of skin breakdown or redness was admitted , zinc oxide would be ordered and treatment would begin as a preventative. ADON A stated she first learned of Resident #11's pressure ulcer the prior week when it was reported to her. She stated at the time a pressure ulcer was identified, she was responsible to write the care plan. She stated she did not usually write a care plan for "the potential for skin breakdown," and said she was only involved in the care of the pressure ulcer once it opened up. ADON A stated the air mattresses and wheelchair cushions were ordered when a resident presented with a Stage II (or higher) pressure ulcer. ADON A stated the care plan for the wounds/pressure ulcers were kept on the treatment cart. Interview with the DON on 05/15/14 at 3:45 PM, revealed Resident #11 was admitted to the facility with redness to her backside and had pain, which was mostly associated with her arm. The DON stated the resident was not very mobile after admission and spent most of her time in bed. The DON stated the resident was not care-planned until the pressure ulcer developed, as they "usually don't care plan skin." The DON stated the resident was at risk for developing pressure ulcers due to her inactivity, diabetes, and history of pressure ulcers. She stated the resident was care-planned after the pressure ulcer presented and they did not have preventative measures or care plans other than applying the barrier cream and frequent repositioning. The DON stated the air mattress and wheelchair cushions were only implemented when a resident had a Stage II or greater pressure ulcer. The DON stated the MDS nurse was responsible for writing care plans and the ADON wrote care plans specific to wounds/pressure ulcers. The DON then stated she would begin working on an admission assessment tool regarding skin and the potential for breakdown. Interview with CNA G on 05/15/14 at 4:20 PM revealed she would let the nurse know if an area on a resident had opened up. CNA G stated she would turn and reposition residents, who were not mobile to prevent pressure ulcers from developing. CNA G stated Resident #11 spent a lot of time in bed when she was first admitted , but had become more independent as her strength increased. Interview with CNA E on 05/15/14 at 4:30 PM revealed she would report any new redness, open areas or bruising to the nurse. She stated she applied barrier cream to the reddened areas and tried to reposition the residents frequently. CNA E stated she remembered seeing the reddened area on Resident #11 when she was admitted . She stated it appeared like a "reddish, pilling/bumpy-like area." She stated the nurses assessed the area and she would put barrier cream on the area until it opened up, and then the nurses would care for the area. Interview with LVN F on 05/15/14 at 4:45 PM revealed she was the nurse who admitted Resident #11 to the facility. She stated she saw the reddened area on her sacrum and noted it on the assessments. LVN F stated she wrote the order for the barrier cream and started the initial care plan. LVN F stated Resident #11 was mostly in bed if she was not in therapy due to the pain. Resident #11 would complain about pain in her arm mostly, and would also complain that her bottom was sore. LVN F stated residents did not get air mattresses or chair cushions until an area on the skin had opened. Review of the facility's Short-Term Care Plan for Resident #11, dated 05/07/14, identified the following problem: "Patient with Impaired Skin Integrity - Pressure Ulcer stage 3 - location-sacrum. Goal: Patient will improve skin integrity over the next four weeks. Interventions: Preventative mattress, wheel chair cushion in chair, multivitamin with minerals, stress tabs with zinc twice a day for 10 days, Vitamin A 8,000 IU by mouth for 10 days, Increase protein daily with [MEDICATION NAME], If incontinent barrier cream after each incident, weekly skin assessment, measure and evaluate weekly, apply treatment/dressing as ordered...." Review of the facility's Wound Treatment and Progress Record for Resident #11, dated May 2014, indicated the drainage of the pressure ulcer was moist and yellow with red surrounding skin. Review of the facility's undated policy and procedure for Routine Skin Care revealed the following: "Use appropriate pressure relieving devices for bed and chair, turn and position at least every two hours in bed and relieve position when in chair...off load/pad boney (sic) prominences as necessary, provide incontinent care as needed, all stage three and four pressure ulcers will be placed on a specialty mattress." Retrieved on 05/29/14 from www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ reflected the following: The National Pressure Ulcer Advisory Panel (NPUAP) "redefined the definition of a pressure ulcer and the stages of pressure ulcers in 2007, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers...A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear...Stage I: ...Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue...Unstageable/Unclassified: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed...Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. may include a thin blister over a dark wound bed." 2) Resident #4 was observed lying in a low bed on 05/13/14 at 9:50 AM, during initial observation rounds with LVN I. The resident was alert and awake, but was unable to respond to questions because of [MEDICAL CONDITION] from a previous stroke. Resident #4 made eye contact and could sometimes reply with one word answers. Most of her speech was garbled. The resident was receiving continuous feeding from a pump through her gastrostomy tube. The resident was lying on her back on the scoop mattress without any positioning devices and/or pillows in place. Further observations of Resident #4 on 05/13/14 at 11:00 AM, 1:30 PM, 2:30 PM, 3:30 PM and 4:30 PM, revealed the resident to be in her bed, and positioned on her back with no positioning devices or pillows visible. During that period of time, the surveyor never observed the resident positioned on her side. The surveyor did not observe pillows on Resident #4's bed or in her room, which could be used for repositioning. Observation of Resident #4 on 05/14/14 at 7:30 AM, revealed the resident was sitting in her wheelchair in the lobby of the facility. At noon that same day, the resident was observed back in her bed, positioned on her back with no pillows or positioning devices visible. Resident #4's MDS assessment, dated 01/07/14, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. It further reflected she could hear well, but had unclear speech. She understood others, but could not make herself understood. She was totally dependent on staff for activities of daily living and incontinent of bowel and bladder. Under the section for Skin Conditions, she was considered a risk for developing a pressure ulcer. An ADL Reference Sheet for Resident #4, dated 01/01/14, reflected under Bed Mobility, that the resident was not able to roll independently from side-to-side in bed. An explanation of this indicated the resident "does not move around in bed, must be repositioned by staff." Resident #4's ADL Assessment, dated 10/02/13, reflected under Bed Mobility, the resident required extensive assist of two persons for turning in bed. Review of the facility's Braden Scale for Predicting Pressure Sore Risk for Resident #4, dated 09/04/13, was scored "14" or at moderate risk for developing a pressure ulcer. Review of Wound Care Specialist Evaluation, dated 03/11/13, revealed the Wound Care Specialist had been consulted for Resident #4, for a shear wound (pressure ulcer) of the lower sacrum of at least 41 days duration. The pressure ulcer measured 0.4 cm x 1.5 cm. The recommendation of the physician was to off-load the pressure ulcer and reposition per facility protocol. In an interview with ADON B on 05/15/14 at 2:45 PM, the surveyor asked what length of time Resident #4 was up in her wheelchair every day. ADON B stated Resident #4 was usually sitting in her wheelchair for two to three hours during the day shift, and two to three hours during the evening shift. The remaining six to seven hours, Resident #4 was in bed. The surveyor asked ADON B if Resident #4 was positioned off her back when she was in bed. ADON B replied she was. He stated she would try to turn herself back to her back. The surveyor asked where the pillows were, which were used for turning and repositioning the resident. ADON B went into the room with the surveyor and looked. No pillows to be used for turning and repositioning Resident #4 were apparent. The only pillow seen by the surveyor at that time was under Resident #4's head. ADON B said he would get pillows and put them in the room. In an interview with the DON on 05/15/14 at 3:30 PM, the surveyor asked the DON how long Resident #4 was in her chair every day. The DON replied the resident was up her wheelchair two to three hours depending on her tolerance for sitting up. When the surveyor asked if she was turned when she was in bed, the DON said the residents, who stayed in bed, were supposed to be turned every two hours. She stated the staff was supposed to be turning them. When the surveyor told the DON she did not see any pillows used for positioning, the DON said she would look into that. Observation of Resident #4 on 05/14/14 at 11:20 AM revealed the resident was making sounds and motioning to her brief. She was positioned on her back. The surveyor found CNA H, who came in to do incontinent care for the resident and changed her brief. The CNA removed the old brief and cleaned the groin and urethral area. The resident was then turned to her left side and a small amount of light colored stool was cleaned from above the rectal area. The surveyor was unable to determine if the resident's skin had any reddened areas, and no opening or breakdown on her skin was seen. After cleaning, CNA H began to put a new brief on the resident. The surveyor asked if barrier cream was applied to the rectal area. CNA H stated there was none in the room and offered to leave and get some. He stated the nurses had the barrier cream on their carts. After incontinent care, Resident #4 was observed to be positioned on her back again. Observation of the Clean Linen room on 05/16/14 at 10:30 AM, revealed three pillows. Observation of the Laundry area revealed four pillows, which could be used for turning and positioning. Observation of Resident #4's room on 05/16/14 at 10:50 AM, revealed the resident was positioned on her back on the scoop mattress. There was one pillow on a chair in her room and one pillow under the resident's head. The facility's current Routine Skin Care policy and procedures, which was undated but titled "Senior Care Centers, 13RSC0412" reflected the following: "1) Use appropriate pressure relieving devices for bed and chair. 2) Turn and position at least every two hours in bed and relieve position when in chair." Review of Resident #4's care plan, dated 04/30/14, revealed the resident was considered at risk for Skin Breakdown related to Impaired Bed Mobility and Alteration in Nutrition. Approaches listed for this problem included: "Monitoring resident for incontinence every 2 hours and as needed, change promptly. Assist with repositioning as needed, using padding between pressure areas. Provide pressure relieving devices as needed. Turn and reposition every 2 hours as needed." The facility's Resident Census and Conditions of Residents Form CMS-672 completed and signed by MDS Coordinator J on 05/13/14 reflected there was one resident listed as bedfast all or most of the time, four residents listed with pressure ulcers and 45 residents receiving preventive skin care.